Rockefeller medicine men : medicine and capitalism in America

E. RICHARD BROWN

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Medicine and
Capitalism in
America

E. Richard Brown

University of California Press, Berkeley, Los Angeles, London

Excerpts from Abraham Flexner,

Abraham Flexner: An Autobiography,

copyright © 1940 by Abraham Flexner and

© 1960 by Jean Flexner Lewison and Eleanor Flexner,

reprinted by permission of Simon & Schuster.

University of California Press
Berkeley and Los Angeles, California

University of California Press, Ltd.
London, England

Copyright © 1979 by

The Regents of the University of California

First Paperback Printing 1980

ISBN 0-520-04269-7

Library of Congress Catalog Card Number: 7&-65461

Printed in the United States of America

123456789

To Marianne, Delia, and Adrienne

Contents

Acknowledgments xi

Introduction 1

Doctors 5

Other Interest Groups 7

Foundations and the State 8

"Wholesale Philanthropy": From Charity to Social
Transformation 13

Creating Private Fortunes and Social Discontent 14

Driving the Reluctant Poor from Poverty 20

Training Scientific Heads to Direct America's "Hard Hands" 24

Carnegie's "Gospel of Wealth" 30

Reverend Gates Introduces Rockefeller to "Wholesale

Philanthropy" 32
The Reverend Frederick T. Gates: The Making of a Rockefeller

Medicine Man 38
The General Education Board: $129 Million for Strategic

Philanthropy 43
Social Managers for a Corporate Society 50

Scientific Medicine I: Ideology of Professional Uplift 60

American Medicine in the 1800s 61

Incomplete Professionalization 67

Medicine as Science 71

Gaining Public Confidence 74

Reducing Competition 80

Technical Requirements of Scientific Medical Education 80

via I Contents

"Nonsectarian" Medicine Undermines the Sects 88
Specialization: Less Competition for the Ehte 91
Gains and Losses 94

3. Scientific Medicine II: The Preservation of Capital 98

Medical Technology and Capital 98

Welch: A Rockefeller Medicine Man 102

Rockefeller Money and Medical Science: A Social Investment 105

Homeopathy: The Conflict Simmers 109

Scientific Medicine and Capitalist Gates 111

Healthier Workers 112

Ideological Medicine 119

Gates' Digression 130

A Permanent Investment 132

4. Reforming Medical Education: Who Will Rule
Medicine? 135

Practitioners Gain a Foothold 136

Council on Medical Education 138

Money for Medical Education: Who Will Pay? 141

Help from the Carnegie Foundation 142

The "Flexner Report" 145

The General Education Board: Medical Education Gets a Different

Drummer 156
Full Time: "Gold or Glory" 158
Selling the Full-Time Proposal 164
Boston Brahmins Resist 166
Fear and TrembUng in the Board Room 167
State Universities: Professionals, the State, and Corporate

Liberalism 176
Summing Up 188

5. Epilogue: A Half-Century of Medicine in Corporate
Capitalist Society 192

Frederick T. Gates and the Rockefeller Philanthropies 193

RATIONALIZING THE MEDICAL MARKET 795

The Committee on the Costs of Medical Care 195
Doctors and the Capital-Intensive Commodity Sector 197
The State: Rationalizing the Private Market 200
The Growth of Capital-Intensive Commodities 203
The "Corporate Rationalizers" 204
The State and Capitalist Medicine 207

Contents I ix

Up Against the Medical Market 212

National Health Insurance: More of the Same 216

TECHNOLOGICAL MEDICINE 218

Scientific Medicine: Beliefs and Reality 218

Life, Death, and Medicine 219

Tapping the State Treasury 225

A "Superacademic General Staff' 226

The Corporate Class 228

The Medical-Industrial Complex 231

Technology in Crisis 233

Blaming the Victim: New Prominence for an Old Ideology 235

CONCLUSION 238

Notes 243
Index 273

Acknowledgments

The idea for this book grew out of my teaching about the poHtical
economy of health care. My students and I asked how the present
system came to be. The search for answers led me to histories of
medicine, pubhshed materials in journals of the period, and the
archival files of the Rockefeller and Carnegie philanthropies. The
archives provided a rich record of the thoughts, policies, and
actions of some of the most influential persons in the history of
American medicine.

The search culminated in this book. But the book would not
have been possible without the generous help, enthusiastic
interest, and personal support of many people. I am especially
grateful to Howard Waitzkin, WilHam Kornhauser, Barbara
Ehrenreich, Gert Brieger, and Michael Pincus, all of whom gave
me detailed and thoughtful criticisms on major portions of the
manuscript together with great encouragement. I also received
helpful criticism and support from Anne Johnson, Jon Garfield,
Charlene Harrington, Barbara Waterman, James O'Connor, Dan
Feshbach, Ivan lUich, David Horowitz, June Fisher, Kathryn
Johnson, Jack London, Jane Grant, Tom Bodenheimer, Sara
Mclntire, Joe Selby, Larry Sirott, and Myrna Cozen. Howard
Berliner has been an exceptional colleague, sharing ideas and
material in a cooperative effort to understand these sparsely stud-
ied issues.

Marianne Parker Brown, my wife, gave me continuing
encouragement and intellectual criticism and support, even when
the burdens of family and household fell disproportionately on
her shoulders. My daughters, Delia and Adrienne, were under-

xii I Acknowledgments

standing beyond their years while their father was "working on
his book."

The staffs of the Rockefeller Foundation Archives and the
Rockefeller Family Archives (now combined in the Rockefeller
Archive Center) and the Carnegie Foundation for the Advance-
ment of Teaching were very helpful in providing convenient
working facilities and making my research in New York excitingly
productive. The staffs of the Health Sciences Information Service
and the Library Delivery Service at the University of California
saved me innumerable hours of retrieving books and journals
from the far-flung libraries on the Berkeley campus.

Eva Scipio, Ruth McKeeter, and Sandra Golvin skillfully
typed portions of the manuscript in its various phases. Estelle
Jelinek carefully and thoughtfully copy edited the final manu-
script.

Much of the research for the last chapter was done while I was
a consultant to the Childhood and Government Project at the
University of California Law School. The Health and Medical
Sciences Program, also at Berkeley, helped defray the costs of my
research trip to the archives in New York.

The Rockefeller Archive Center and the Carnegie Founda-
tion for the Advancement of Teaching kindly gave me permission
to publish excerpts from their files.

Introduction

The crisis in today's health care system is deeply rooted in the
interwoven history of modern medicine and corporate capitalism.
The major groups and forces that shaped the medical system
sowed the seeds of the crisis we now face. The medical profession
and other medical interest groups each tried to make medicine
serve their own narrow economic and social interests. Founda-
tions and other corporate class institutions insisted that medicine
serve the needs of "their" corporate capitalist society. The dia-
lectic of their common efforts and their clashes, and the economic
and political forces set in motion by their actions, shaped the
system as it grew. Out of this history emerged a medical system
that poorly serves society's health needs.

The system's most obvious problems are the cost, inflation,
and inaccessibiUty of medical care in the United States. Total
health expenditures in this country topped $200 billion in 1979,
nearly $1,000 for every woman, man, and child. Far more of
society's resources now go into medical expenditures than ever
before; twice the portion of the Gross National Product was
spent on medical care in 1980 than in 1950.

We pay for these costs through our taxes, health insurance
premiums, and directly out of our pockets. Public expen-
ditures— four out of every ten dollars spent on personal health
services — come out of our taxes. Private health insurance and di-
rect out-of-pocket payments each account for about three out of
every ten dollars. No matter what form it takes, the entire $200
billion originates in the labor of men and women in the society.
President Carter estimated that the average American worker

2 / Introduction

works one month each year just to pay the costs of the medical
system.'

Most people feel they should be getting a lot for this money,
but instead they find that it is difficult even to get the care they
need. Primary care physicians — general practitioners, pediatri-
cians, internists, and gynecologists — are scarce. Doctors and
hospitals are clustered in the "better" parts of our cities and
largely absent from the poorer sections and rural areas of our
country. For the millions of Americans covered by Medicaid (the
government subsidy program for the public assistance-linked
poor), the coverage has been as sparse and degrading as the de-
meaning clinics it was supposed to replace. The middle class and
the poor share at least long waiting periods for doctors, one of the
most common constraints on the accessibility of physicians. In-
stead of creating a humane and accessible medical care system,
Medicare and Medicaid have helped fuel inflation in medical costs
by dumping new funds into a privately controlled system ready to
absorb every penny into expansion, technology, high salaries,
and profits.

A second, somewhat less widely discussed, problem is the
relatively small impact medical care makes on the population's
health status. Despite a plethora of new diagnostic procedures,
drugs, and surgical techniques, we are not as healthy as we
beheved these medical wonders would make us. Some critics, Uke
social philosopher Ivan Illich,^ accuse medicine of making us
sicker — physically, politically, and culturally — than we would be
without it. Many analysts have documented the medical profes-
sion's social control functions, medical technology's frequently
adverse effects on our health, and medicine's neglect of impor-
tant physical and social environmental influences on our health.^
Instead of medicine Hberating us from the suffering and depen-
dency of illness, we find that its oppressive elements have grown
at least as rapidly as its technical achievements.

Why has medical care grown so costly so rapidly? Why is it so
plentiful and yet so inaccessible? How did medicine become
technically so sophisticated but remain socially unconcerned and
even repressive?

A popular but too facile answer is that such problems are
characteristic of technology and industrialized societies. Accord-
ing to this argument, technology and industrialization impose

Introduction I 3

their own limits on forms of social organization and produce
similar kinds of problems that call forth similar solutions. Medical
sociologist David Mechanic finds problems of cost, organization,
and ethical dilemmas in medicine widespread among industri-
alized countries and concludes that "the demands of medical
technology and the growth of the science base of medical activity
produce pressures toward common organizational solutions
despite strong ideological differences.'"^ lUich asserts that "patho-
genic medicine is the result of industrial overproduction."^ In this
view, technology has a life of its own, imposing its imperatives on
individuals and social organization. By focusing on widespread
patterns of industrial organization and technological develop-
ment, these analysts conclude that technology and industrializa-
tion are universal determining forces.

Such technological determinism ignores the particular history
in which society and technology interact. In the Marxian view,
technology and economic organization constantly shape each
other in a dialectical process. Individuals and groups who own the
resources and control the organization of production, far from
being at the mercy of "neutral" technology, introduce innova-
tions that serve their own ends and oppose those that would serve
other interests than their own. These innovations may neglect
broader community needs and may hurt the interests of others.
Machines and factories undermined the autonomy and even the
economic existence of independent craft workers. Hospitals and
their expensive equipment may tie many health workers to
monotonous jobs and use funds that might otherwise go for more
widely distributed community clinics. Those affected by these
technological developments may resist them and force their
modification. Workers may organize into unions and gain some
control over the relations of production. Communities may
organize to block hospital expansion and force development of
more community-based clinics. In sum, the political-economic
organization of society generates certain types of technological
innovation and not others, and these innovations generate new
social forces that modify technology and poUtical-economic
relations.^

This book sees scientific, technological medicine not as the
determining force in the development of modern health care but
as a tool developed by members of the medical profession and the

4 / Introduction

corporate class to serve their perceived needs. Individuals and
groups who possess needed resources can apply them to develop
certain types of technological innovation in medicine. Those who
have the requisite resources can also apply the resulting techno-
logical innovation to serve their economic and social needs.

In the United States medicine came of age during the same
period that corporations grew to dominate the larger economy.
As corporate capitalism developed, it altered many institutions in
the society, medicine among them. Its influence was created not
simply through cultural assimilation or the demands of industrial
organization but by persons who acted in its behalf. This inter-
pretation does not suggest that history is made by dark conspira-
cies. Rather, it argues that the class that disproportionately owns,
directs, and profits from the dominant economic system will
disproportionately influence other spheres of social relations as
well.

Members of the corporate class, including those who own
substantial shares of corporate wealth as well as the top managers
of major corporate institutions, naturally try to ensure the
survival of capitalist society and their own positions in its social
structure. In the case of medicine, members of the corporate
class, acting mainly through philanthropic foundations, articulat-
ed a strategy for developing a medical system to meet the needs
of capitalist society. They believed their goals for medicine would
benefit the society as a whole, just as they beUeved that the
private accumulation of wealth and private decisions about how
to use that wealth and its income were in the best interests
of society. In this book, we will examine the strategies they
developed during the Progressive era and the reasons for their
actions, leaning heavily on the public and private thoughts of
some persons centrally involved in these efforts. We will describe
and analyze the interests and strategies of the medical profession
and of the corporate class as they developed independently,
coalesced, and then clashed. We will also see that the government
has increasingly taken over the strategies and struggles begun by
the corporate class.

The corporate class influenced medicine, but it could not
control it absolutely. The market system in medical care provides
special interest groups — today including doctors, hospitals, insur-
ance companies, drug companies, and medical supply and

Introduction I 5

equipment companies — ^with the opportunity to develop their
own bases of economic power, enabhng them to carve out and
defend their turfs in the marketplace. The larger business class
stands "above" these interest groups, trying to tame and coordi-
nate the leviathan but nonetheless committed to private owner-
ship and control and also enjoying medicine's legitimizing and
cultural functions. The relationships and the contradictions that
emerged among the corporate class and these medical interest
groups profoundly influenced the organization and content of
today's medical system.

DOCTORS

From our vantage point today it is difficult to beheve that in
the late nineteenth century the medical profession lacked power,
wealth, and status. Medicine at that time was plurahstic in its
theories of disease, technically ineffective in preventing or curing
sickness, and divided into several warring sects. Existing profes-
sional organizations had virtually no control over the entry of new
doctors into the field. Physicians as a group were merely scattered
members of the lower professional stratum, earning from several
hundred to several thousand dollars a year and having no special
status within the population.

By the 1930s, however, medicine was firmly in the hands
of an organized profession that controlled entry into the field
through licensure and accreditation of medical schools and teach-
ing hospitals. The profession also controlled the practice and eco-
nomics of medicine through local medical societies. "Medicine"
had come to mean the field of clinical practice by graduates of
schools that followed the scientific, clinical, and research orienta-
tions laid down by the American Medical Association (AMA)
and by Abraham Flexner in a famous report for the Carnegie
Foundation. All other healers were being excluded from practice.
Physicians were increasingly drawn only from the middle and
upper classes. The median net income for nonsalaried physicians
in 1929 was $3,758, above the average for college teachers but
below the faculty at Yale University and below the average for
mechanical engineers. "^ Overall, doctors were rapidly rising in
income, power, and status among all occupational groups.

In the 1970s physicians have continued to climb to the top

6 I Introduction

rungs of America's class structure. The" median net income of
office-based physicians — $63,000 in 1976 — places them in the top
few percentiles of society's income structure. In 1939 the average
earnings of doctors were two and a half times as great as those of
other full-time workers, but by 1976 the gap had increased to five
and a half times. Doctors rank with Supreme Court justices at the
top of the occupational status hierarchy. And in recent public
opinion polls, more Americans said they trusted the medical
profession than any other American institution — including higher
education, government (of course), and organized rehgion.^

Rising "productivity" has been an important factor in physi-
cians' efforts to raise their incomes, status, and power. The
medical profession has drastically controlled the production of
new physicians and has delegated to technicians and paraprofes-
sionals below them the tasks they no longer find interesting or
profitable. With rapidly expanding medical technology, more and
more tasks were shifted down the line to a burgeoning health
work force. At the beginning of this century two out of every
three health workers were physicians. Of the more than 4.7
million health workers today, only one in twelve is a physician.
Thus, doctors have increasingly become the managers of patient
care rather than the direct providers of it.^

As medical managers, physicians have found themselves
drawn out of private practice into employment in hospitals, re-
search, teaching, government, and other institutions. Today four
in ten doctors are employed in such institutions, compared with
one in ten in 1931 . These physicians have had fewer material inter-
ests in common with private practitioners and have shown little
pohtical support for the AMA.^°

Physicians entered a struggle to maintain their position at the
top of the medical hierarchy soon after that position was won.
The challenge has not, for the most part, come from below,
except for recent attempts by nurses to increase their authority in
patient care. Doctors have found themselves in a struggle with
hospitals, insurance companies, medical schools, foundations,
government health agencies, and other groups with an interest in
a more rationalized health system — one in which the parts are
more coordinated hierarchically and horizontally and in which
more emphasis is given to capital-intensive services. The conflict
has emerged between organized practitioners as one interest

Introduction I 7

group, what Robert Alford calls "professional monopolizers,"
and all the groups seeking to systematize health care according to
bureaucratic and business principles of organization, what Alford
calls "corporate rationalizers.'"'

OTHER INTEREST GROUPS

In challenging the power of organized medicine to protect its
interests, hospitals, particularly through the American Hospital
Association (AHA), have tried to appear the "logical center" of
any rationalized health system.'^ In their transformation and
growth from asylums for the sick and dying poor to their
twentieth-century role as the physician's workshop, hospitals
developed a powerful position in modern health care as the major
locus of medical technology. Because of physicians' growing
reliance on technology, hospitals were absorbing an increasing
share of dollars spent on medical care. PubHc and private health
insurance (really, medical care insurance) developed as a stable
source of income, enabling hospitals to expand their facihties.
Collectively, hospitals have become a major force in the medical
system, consuming 40 percent of the nation's annual health care
expenditures. Blue Cross and Blue Shield (the "Blues"), created
in the 1930s and 1940s by hospital associations and medical socie-
ties, respectively, together with commercial insurance companies
now control 30 percent of medical care expenditures, mostly em-
phasizing hospital-based technical care. They have developed
economic and political clout commensurate with their dominating
fiscal role.

While the insurance industry is a new voice in the chorus of
corporate rationalizers, medical schools have been in the van-
guard for more than half a century. Although run by physicians
— for the reproduction of health professionals and as the research
and development arm of the medical industry — medical school
interests have often conflicted with the interests of practitioner-
dominated medical societies. In the nineteenth century, medical
schools were generally run by small groups of doctors for their
own financial benefit. During most of the twentieth century,
medical schools have been university-controlled and respon-
sive to the interests of foundations and, since World War !•,
government funding sources. For the brief period from about

8 I Introduction

1900 to World War I , science-oriented medical schools and the AMA
joined forces to press for the acceptance of scientific medi-
cine. Since that time they have gone their separate ways — the
AMA struggling to preserve the dominance and incomes of private
practitioners, and medical schools fostering more rationalized
medical care, usually with physicians as top management.

Hospitals, insurance companies, and medical schools all have
a relatively greater interest than doctors in promoting capital-
intensive, rationalized medical care. While expanding medical
technology helped doctors increase their status and incomes, it
has been the raison d'etre of hospitals, medical schools, and even
insurance companies. Medical technology's demands for heavy
capital investment also encourage rationalization of medical re-
sources— centralization and coordination of capital, facihties, ex-
penditures, income, and personnel.

FOUNDATIONS AND THE STATE

Besides these interest groups, two other forces — the govern-
ment and foundations — have exerted a powerful influence in
favor of rationalizing medical care. Although the government has
been the dominant influence since World War II, foundations
were the major external influence on American medicine in its
formative period from 1900 to 1930. Their source of power has
been the purse, generously but carefully appHed to specific
programs and policies. Neither foundations nor the government
has operated as an interest group in the manner of doctors,
hospitals, insurance companies, medical schools, and the drug
and hospital supply industries. The enormous sums they expended
— from foundations some $300 million from 1910 through the
1930s and from the federal government many billions of dollars
since World War II, for medical research and education alone —
have not been for their own financial enrichment.

The argument developed and supported in this book suggests
that both foundation policy and government policy have served
the interests of certain medical groups but only because the
interests of these groups coincided with those of the larger
corporate class. As evidence from the historical record will show,
the programs of foundations earher in this century were explicitly

Introduction I 9

intended to develop and strengthen institutions that would extend
the reach and tighten the grasp of capitalism throughout the
society.

In medicine the major objectives of foundations were: to
develop a system of medicine that would be supportive of capital-
ist society; and to rationalize medical care to make it accessible
to those whom it was supposed to reach but at the least cost to
society's resources. These objectives created their own contradic-
tions. At first, foundations aligned themselves with the aims and
strategies of the medical profession, but they soon rejected the
narrow interests the profession wished to serve and moved quickly
to expand the roles of medical schools and hospitals and to
support their dominance over all medical care. By World War
II, when the role of the State* in governing the capitalist econ-
omy was fully established, the federal government took over the
foundations' leading role in medicine, continuing the basic stra-
tegy adopted by the foundations more than two decades earlier
and opening the floodgates of the treasury to implement it.

In the first chapter, we will see how philanthropic foundations
emerged from several parallel developments of capitalist society
in the latter nineteenth century. While many members of the new
wealthy class were supporting charities to ameHorate the disrup-
tions and deprivations imposed on large numbers of people by
capitalist industrialization, others recognized the need for techni-
cally trained professionals and managers and supported the
development of universities and professional science. Just after
the turn of the century men of great wealth, Uke John D.
Rockefeller and Andrew Carnegie, created philanthropic founda-
tions with professional managers in charge of their charitable
fortunes. With the Rockefeller philanthropies in the lead, these
foundations developed strategic programs to legitimize the funda-
mental social structure of capitalist society and to provide for its
technical needs.

Chapter 2 traces the social and economic role of scientific
medicine in the history of the American medical profession.

*Throughout this book, capitalized "State" refers to the political institutions and
agencies of government which embody society's political authority. Uncapitalized "state"
refers to the individual states in the United States.

10 I Introduction

Modern scientific medicine was not merely a "natural" outcome
of combining science and medicine in the nineteenth century.
Apart from the concrete scientific developments that permitted
the appHcation of scientific thought and investigation to problems
of disease, scientific medicine had equally important social and
economic origins. It was an essential part of a strategy articulated
by reform leaders of the medical profession to enhance the
profession's position in society, and it succeeded because it won
the support of dominant segments of the American class struc-
ture.

Scientific medicine gained the support of the American med-
ical profession in the late nineteenth century because it met the
economic and social needs of physicians. By giving doctors greater
technical credibility in society, it saved them from the igno-
minious position to which the profession had sunk. Moreover,
scientific medicine became an ideological tool by which the dom-
inant "regular" segment of the profession restricted the produc-
tion of new doctors, overcame other medical sects, temporarily
united leading medical school faculty and practitioners, and
otherwise reduced competition.

Despite its appeal for the medical profession, scientific med-
icine would have accomplished Httle for doctors if it had not had
the support of dominant groups in American society. In Chapter
3 we will see the reasons for this capitalist support, especially
through the thinking of Frederick T. Gates, for more than two
decades the chief philanthropic and financial lieutenant to John
D. Rockefeller and the architect of the major Rockefeller medi-
cal philanthropies.

As an explanation of the causes, prevention, and cure of
disease that was strikingly similar to the world view of industrial
capitalism, scientific medicine won the support of the classes
associated with the rise of corporate capitalism in America.
Capitalists and corporate managers believed that scientific medi-
cine would improve the health of society's work force and thereby
increase productivity. They also embraced scientific medicine as
an ideological weapon in their struggle to formulate a new culture
appropriate to and supportive of industrial capitalism. They were
drawn to the profession's formulation of medical theory and
practice that exonerated capitalism's vast inequities and its
reckless practices that shortened the lives of members of the

Introduction I U

working class. Thus, scientific medicine served the interests of
both the dominant medical profession and the corporate class in
the United States.

Nevertheless, a contradiction emerged between the interests
of the medical profession and those of the corporate class. As we
will see in Chapter 4, the private practice profession and the
corporate class clashed over attempts to reform medical educa-
tion. The financing of scientific medical schools required tremen-
dous amounts of capital from outside the medical profession.
Those who provided the capital had the leverage to impose
policy. The lines of the conflict were clearly drawn: Was medical
education to be controlled by and to serve the needs of medical
practitioners? Or was it to serve the broader needs of capitalist
society and be controlled by corporate class institutions?

The Flexner report, sponsored by the Carnegie Foundation,
tried to unify these interests by centering its attack on crassly
commercial medical schools. However, the Rockefeller philan-
thropies, substantially directed by Gates, exposed the contradic-
tion by forcing a full-time clinical faculty system on recipient
schools against the interests and arguments of private practition-
ers. Gates made it clear that medicine must serve capitalist
society and be controlled — through the medical schools that
reproduce its professional personnel and innovate its technique
— by capitalist foundations and capitalist universities. By 1929 one
Rockefeller foundation, the General Education Board, had itself
appropriated more than $78 million to medical schools to im-
plement this strategy, and Gates' perspective was firmly estab-
lished.

Gates was adamant about keeping his strategy free of involve-
ment with the State by not giving money to state university
medical schools. However, within the Rockefeller philanthropies
as within the largest industrial and financial corporations gen-
erally, most officers and directors had come to see the State as
a necessary aid in rationalizing industries, markets, and institu-
tions.

The course that Gates and his contemporaries initiated
continued to develop during the next half-century, but with the
State assuming the dominant financial and political role in ration-
alizing medical care and developing medical technology. As we
will see in Chapter 5, the State's emphasis on technological

12 I Introduction

medicine ignored some of the most important determinants of
disease and death while the economic and pohtical forces of
capitaUst society assured that rationaUzation would not eliminate
the developing corporate ownership and control over the medical
market. How medicine will be contained and rationalized in this
private market system is a contradiction that now plagues the
State and the corporate class as the demand for national health
insurance grows. How medical resources can be transformed into
effective instruments for improving the population's health is a
contradiction imposed on the entire society. These contradictions
and their resulting crises are the legacy of medicine's develop-
ment in capitalist society.

CHAPTER

"Wholesale Philanthropy ":
From Charity to Social
Transformation

Industrialization in nineteenth-century America created many
problems for those who owned and managed the corporations
that came to dominate the economy. Industrial capitalists had to
arrange for adequate capital, obtain raw materials, organize pro-
duction, disciphne a reluctant work force, and develop markets
and transportation systems. They also had to deal with the politi-
cal structures and methods intended for older relations of pro-
duction, centered around agriculture and commerce, that were
only slowly adapting to the new industrial, corporate order. Finally,
they had to reshape older social institutions or create new ones.
Educational, religious, medical, and cultural institutions were
some of the glue that held together the ancien regime. In sum,
the new corporate class had to transform all these economic, politi-
cal, and social institutions to serve their urbanized, industrialized,
and corporate society.

The new economic order created different problems for
classes that owned little or nothing of the new system. American
society had never been tranquil, but industrialization spread deep
disaffection and anger among classes who were dislocated by it
and among those who suffered as a result of capitalist accumula-
tion of wealth. The agrarian and merchant rulers of the formerly
dominant towns resented the meteoric rise of urban industrialists
and bankers. Native craftsmen, foreign immigrants, and dis-

14 I "Wholesale Philanthropy

possessed farmers reluctantly submitted to the factory system.
Unionism, populism, and socialism threatened the power and
wealth of corporations and even raised doubts about the contin-
ued existence of capitalism.

As we will see in this chapter, corporate capitalists turned to
philanthropy, the universities, and then to medicine to solve
some of the many problems that grew out of capitalist industrial-
ization. For the most part, social transformations were led by the
same "unseen hand" that guided the market forces of capitalism;
this self-interest provided a limited perspective for social change.
Only gradually did leading capitalists and their allies consciously
develop broad strategies and supports for the new order they
were building. Philanthropic capitalists supported often harsh but
hopefully ameliorative charity to control the desperate poorer
classes. Others began building universities to meet the new
society's needs for trained experts and managers. A new manage-
rial and professional stratum developed to direct corporations,
universities, science, medical institutions, and philanthropy itself.
After the turn of the century, some philanthropists transformed
foundations into a truly corporate philanthropy,* modeled after
the dominant economic institutions and fueled with their "sur-
plus" wealth. Representatives of the emerging corporate liberal-
ism made these foundations their chief instruments for transform-
ing social institutions, giving corporate philanthropy an historical
role beyond the most visionary dreams of early philanthropic
capitalists. This union of corporate philanthropy, the manager-
ial-professional stratum, and the universities and science spawned
the Rockefeller medicine men and their new system of medicine.

CREATING PRIVATE FORTUNES AND
SOCIAL DISCONTENT

The Civil War was a watershed in American philanthropy, as
it was in nearly all aspects of American life. It was a great
wrenching experience in American history, spreading death and
destruction, stimulating industrial development, and producing

*In this book, "corporate philanthropy" refers to philanthropy characteristic of
corporate capitalism, especially foundations that are philanthropic corporations controlled
by members of the corporate class.

"Wholesale Philanthropy" I 15

upheavals within and between all classes of Americans. A new
kind of philanthropy, tailored to these new conditions, emerged
in the decades following the war.

The Civil War not only freed the black slaves from legal bonds
of slavery. It also freed the hand of Northern capital to extend
throughout the nation the industrial transformation it had begun
mainly north of the Ohio River. As the "underground railroad"
was the vehicle and symbol of freedom for ante-bellum slaves, the
iron railroad was the vehicle and symbol of industrialization and
the ascending capitalist class.

As the railroads were used increasingly to move troops and
suppHes for the Union armies, they helped extend and integrate
the marketplace, making possible a speciaHzed manufacturing
and marketing system that could be coordinated across the
continent. The railroads pushed into every region of the country.
They brought farm produce to new markets and to ports for ship-
ment to distant lands. They carried cotton from Southern fields
to New England textile mills. They carried iron ore from Lake
Superior to the iron mills and new Bessemer steel furnaces in
Pittsburgh, and oil from western Pennsylvania to Cleveland
refineries. And they brought the products from the nation's
factories to markets in every region. Everywhere, they spread
new settlements and development. Despite interruptions during
the Civil War, railroad construction added 62,000 miles of new
lines in the 1860s and 1870s, tripling the nation's existing track
mileage. Railroad construction required iron and later steel rails
and bridges. The railroads themselves soon became the biggest
customers of America's growing steel industry.

The Civil War and the railroads led some men to their pots of
gold. Andrew Carnegie began his rise to fortune as a telegraph
clerk for the Pennsylvania Railroad in 1853. By the beginning of
the Civil War the ambitious twenty-five-year-old Carnegie was
well into railroad management and spent a few months organizing
rail transport and telegraph communications for the War Depart-
ment. But Carnegie quit his exciting and dangerous war front job
and returned to the Pennsy and especially to tend his growing
investment in iron manufacturing and coal mining. By 1863 his
annual income exceeded $40,000.^

John Davison Rockefeller's fortunes were also helped by the
Civil War. In 1861, as the war consumed the energies and lives of

16 I ''Wholesale Philanthropy"

Northerners and Southerners, the twenty-five-year-old Rockefel-
ler was building a successful merchandising firm in Cleveland. As
war orders poured in, commodity prices rose sharply, and
Rockefeller's profits soared. Two years later, Rockefeller had
saved enough capital to invest in an oil refining business, and by
the end of the war he was worth enough to take control of the
company. By 1880, led by Rockefeller's determination to "make
money and still more money," combined with relentless com-
petition in the marketplace and rebates extracted from the rail-
roads, his Standard Oil Company was refining 95 percent of the
country's oil.^

While the industrial base had obviously been growing in the
decades before the Civil War, it was the changes wrought by the
war that cemented the new system's structure. The Southern
patrician class, whose position was based on agriculture and
slaves, was not crushed, but its subordination to the Northern-
controlled capitalist economy was assured. The factory system
was extended with the railroad, and an industrial working class
was formed out of craftsmen and laborers, native folk and
immigrants. Small-town America gradually gave way to industrial
and commercial boom, and cities grew faster than their fragile
tenements could be built. In the process, the older entrepreneurs
and landed gentry were displaced by the new entrepreneurs and
their corporations. By the 1870s, for example, only 520, or 5
percent, of the 10,395 businesses in Massachusetts were incorpo-
rated. But this 5 percent held 96 percent of the total capital and
employed 60 percent of all workers. By 1900 three-fourths of all
manufactured goods were produced by corporations. Because of
the important logistical role of the railroads, the Civil War has
been called the "first railroad war." Yet the war did not rely on
an industrial economy. As William Appleman Williams aptly put
it, the Civil War "produced an industrial system rather than being
fought with one."^ The ultimate victors of the war were the
corporations and the men who, for the most part, ruled the new
economy.

Not all was smooth for the new barons of the corporate
economy, nor did they make life easy for those under them. The
owners of each industry, driven to grab what they could of the
available market and accumulate as much capital as possible in
the shortest time, pushed wages down in order to lower prices

"Wholesale Philanthropy" I 17

and to get a jump on their competitors. Immigrants were
inducted into the growing industrial work force. Some 16 million
foreign-born were attracted to the country in the second half of
the nineteenth century, totaling 15 percent of the population by
1890 and nearly a quarter of the population of the industrialized
northeastern states. Craftsmen saw their skills, the basis of
modest security and pride, fall to degradation and unemploy-
ment before machines that outproduced them and factories that
oppressed them. Migrants from failing farms and immigrants
from foreign lands filled the factories and cities of the New
World. Working men lost their livelihoods or submitted to the
harshest labors. Women were drawn out of more traditional
homebound work into factories, shops, and stores. Twenty
percent of the nation's women were wage laborers by 1900.
Children were sucked into the factories as the cheapest labor.
Working-class family and social Hfe were shaken and devastated.

Exploitation of workers, unmitigated by either legal restraints
or humanitarianism, led to increased organizing by labor. The
depression of the 1870s brought wages in 1875 down to $1.50 for a
ten-hour day. Riots were common in cities throughout the
country. Labor began to organize, and employers used every
available power, from lockouts to Pinkertons, to crush the union
movement. In 1877 the first nationwide strike, a spreading
walkout against the railroads, was put down with a bloodbath that
took the lives of scores of workers, their families, and their
supporters in city slums around the country. The labor movement
grew and strikes continued to spread in the 1880s and 1890s. The
Haymarket Square bomb in 1886, the strike at Carnegie's
Homestead steel mills in 1892, and the Pullman strike in 1894
were only the most prominent events that made employers and
their allies fear for the continued existence of their society. "The
times are strangely out of joint," worried a Kentucky politician.
"The rich grow richer, the poor become poorer; the nation
trembles.""*

Town folk and farmers, especially in the Midwest and South,
felt their lives and livelihoods increasingly determined by railroad
rates and lines of credit from banks directed from distant cities.
Semi-feudal sharecropping kept large numbers of Southern
farmers in perpetual debt and poverty. Agrarian opposition to
capitalist expansion won broad support. In 1896 the growing

J8 I "Wholesale Philanthropy'

Populist party formed a shallow coalition with the Democratic
party around the Democrat Bryan for President and the Populist
Tom Watson for Vice-President against McKinley, the candidate
of big business. The Populist party was decimated by their defeat,
but populist resistance to capitalist wealth and control of agricul-
ture continued in the Granges and the Farmers Union well into
the new century. To the middle-class professionals who dominat-
ed the Progressive movement the society seemed to be breaking
up below them because of the greed of those above them. They
called for reforms to Hmit the concentration of power and wealth.
Many members of the richer class felt called upon to justify
the great inequality that angered the working class and worried
the middle class. Naturally they did not see themselves as "idle"
rich. They viewed their efforts to build industrial empires as
productive work, and they considered all the people to be the
beneficiaries of those empires. No one said it as well as
Rockefeller:

The best philanthropy, the help that does the most good and the
least harm, the help that nourishes civilization at its very root, that
most widely disseminates health, righteousness, and happiness, is
not what is usually called charity. It is, in my judgment, the
investment of effort or time or money, carefully considered with
relation to the power of employing people at a remunerative wage,
to expand and develop the resources at hand, and to give opportuni-
ty for progress and healthful labour where it did not exist before. No
mere money-giving is comparable to this in its lasting and beneficial
results.^

The great benefit of such enterprises is moral, providing
employment to otherwise idle hands, and material, "to multiply,
to cheapen, and to diffuse as universally as possible the comforts
of life."^ Thus, the building up of private industry is the best
method of solving the problems that historically grew with
industrialization. "Can there be any doubt that cheapening the
cost of necessaries and conveniences of life is the most powerful
agent of civilization and progress?" asked Charles Elliott Perkins,
president of the Chicago, Burhngton, and Quincy Railroad. "The
true gospel," Perkins philosophized agreeably, "is to enable men
to acquire the comforts and conveniences of life by their own
efforts, and then they will be wise and good."''

The class of men and women who provided this largess for the
rest of society had varied notions about what to do with their

"Wholesale Philanthropy" I 19

money and their power. Mark Hanna, a Cleveland industrialist,
showed fellow capitalists that the President and executive branch
of the government, as well as the Congress, could be secured "for
the protection of our business interests." Fearing the growing
ranks of Populists and their increasing political strength, he
established an interlocking political directorate of corporate
leaders to organize their common interests and bring their
influence more directly into the federal government. With their
first Presidential triumph, electing McKinley in 1896, they inau-
gurated the modern system of expensive, centrally coordinated
national campaigns. Hanna led the formation of a corporate
politics that placed the broad class interests of industriahsts and
financiers ahead of "pork barrel" tactics favoring narrow interests
that had dominated state, national, and local political scenes.
Hanna and other leaders of this class put together new aUiances,
like the National Civic Federation, with some labor leaders to
create a "harmony of interests" out of the class conflicts that
threatened the new economic order. The Progressive movement
proved an ideal vehicle for the business class to assert its interests
by securing additional, needed capital from the Congress and,
through reforms in the federal executive branch, creating and
controlling regulatory agencies to bring order and consolidation
to a number of industries. The politically wise leaders of this class
thus demonstrated that with strategic alliances with social reform-
ers and conservative union officials, the nation's political institu-
tions could be reformed to serve the needs of the corporate
order. ^

Not all capitalists, however, could see farther than their own
immediate interests in pohtics. John D. Rockefeller, whose
Standard Oil Trust was accused by Henry Demarest Lloyd of
buying out the legislatures and the executive branches of
Pennsylvania and Ohio, was unenthusiastic about his friend
Hanna's broader political strategy. Hanna's first major success
sent John Sherman to the U.S. Senate in 1885, ironically pro-
viding the author of the very law under which the Standard em-
pire was eventually broken up. Perhaps Rockefeller suspected
such betrayals from politicians who had their own visions of what
was good for business, for he customarily reserved his political
contributions for candidates closer to the Standard's immediate
fields of operations.^

Many wealthy men spent their fortunes on ostentatious luxury

20 I "Wholesale Philanthropy*

that left much of the European aristocracy in shadow. The
Vanderbilts, Jim Fisk, Jay Gould, and other financiers built
palaces along New York's Fifth Avenue, many of them with
marble, furnishings, and statuary scooped up from the crumbling
baronies of the Old World. Marshall Field and Potter Palmer
built their castles on some of Chicago's most prized residential
and lakefront land. Mark Hopkins, Charles Crocker, and Leland
Stanford transformed San Francisco's Nob Hill with their resi-
dences of splendor, using wealth obtained from promoting and
governing the westward expansion of the railroads. Carnegie
bought himself a castle in his Scottish homeland. And Rockefel-
ler created, not merely a castle, but a royal estate at Pocantico
Hills, whose 3,500 acres overlooking the Hudson River was five
times the size of Central Park. The spectacle of such living,
especially in the midst of tenement-teeming cities, caused con-
siderable agitation. The Massachusetts Board of Education had
complained even in 1849, "One gorgeous palace absorbs all
the labor and expense that might have made a thousand hov-
els comfortable." By the end of the century, social scientists
cultivated by the wealthy came to their benefactors' defense. A
Boston University economics professor retorted to detractors of
grandeur, "The notion there is necessarily any causal connection
between opulence and poverty is too crude to require serious
refutation. "^°

DRIVING THE RELUCTANT POOR FROM POVERTY

Some representatives of the opulent class, both before and
after the Civil War, had a broader sense of purpose. They
provided luxurious, even princely lives for themselves and their
families, but they carefully set aside a share of their wealth
for philanthropy. Philanthropy, of course, did not mean giving
money directly to the poor. While charity had always implied
providing alms for the relief of the poor, the rich and most social
reformers in the class immediately below the rich have always
been wary of the consequences of giving to the poor. Cotton
Mather urged colonial Boston merchants to set a disciplined,
moral example and give only to the "poor that can't work."
Benjamin Franklin hoped to provide sufficient opportunity in
society so there would be no need of poverty, and he tried to

"Wholesale Philanthropy" I 21

develop a strategy for getting the poor to adopt disciplined ways
of living. "I think the best way of doing good to the poor,"
Franklin said, "is not making them easy in poverty, but leading
them or driving them out of it."^^

Franklin's maxim and a pitiless Social Darwinist perspective
were the heart of the charity organization movement that
blossomed in the United States during the last three decades of
the century. Patterned after the London Charity Organization
Society, founded in 1869, these city and national organizations
gave few handouts. Their main purpose was, in the words of a
Philadelphia group, to develop "a method by which idleness and
begging, now so encouraged, may be suppressed and worthy
self-respecting poverty be discovered and relieved at the smallest
cost to the benevolent." Even during the vast depression that
began in 1873 and lasted until the end of that decade, all takers of
charity were suspected of slothfulness and degeneracy. ^^

The poor were a desperate, volatile lot, given to crime, riots,
and insolent discontent. Extreme Social Darwinists believed with
Herbert Spencer that those who are fit to live do so and those
who are not fit die — "and it is best they should die."'^ But the
dominant classes of any society need a more positive program
than that to deal with oppressed classes' articulated demands for
sharing the wealth or even their inarticulate mayhem.

The programs that emerged from charity organization work
brought systematic study and the label of "science" to philan-
thropic work. The annual meetings of the National Conference
of Charities and Correction brought together experts from char-
ity organizations, administrators of penal institutions, hospitals
and settlement houses, academics from university sociology and
economics departments, and clergymen and physicians to coordi-
nate their work and develop strategies for uplifting the poor. The
attitudes of these "scientific" charity workers ran from harsh to
refined, punitive to ameliorative.'"* Over the years these reform-
ers turned increasingly to the analytic methods of the social
sciences and to the political views of the Progressive movement.
Edward T. Devine, in his presidential address to the National
Conference in 1906, noted that inmates were entering charitable
institutions, insane asylums, prisons, and reformatories "faster
than all our educational processes, our relief funds, and even our
consecrated personal service" have been able to rehabilitate

22 I ''Wholesale Philanthropy"

them. The role of "modern philanthropy," Devine continued, is
to "seek out and to strike effectively at those organized forces of
evil, at those particular causes of dependence and intolerable
living conditions which are beyond the control of the individuals
whom they injure and whom they too often destroy. "^^

Scientific philanthropy must concern itself with "prevention
rather than relief," argued Amos Warner, a Stanford economist
active in the movement. Warner compared statistics compiled
by charity organizations in the United States and Europe and
concluded that nearly three-fourths of all poverty is due to per-
sonal or social "misfortune" and less than a fourth to "miscon-
duct" on the part of the individual.'^ "Prevention" involved inter-
vening in the lives of both groups to assist them through their
misfortune or change their bad habits and lead them onto the
path of righteousness.

Out of this social intervention perspective and the charity
organization movement emerged the social work professions.
Case workers, settlement house workers, correctional adminis-
trators, probation officers, and their academic advisers shared
with the middle and upper classes the prevaiHng Social Darwinist
view that dependent poverty, crime, and social deviance in
general had biological roots. But this new professional class
believed that medical and social intervention could remedy
"natural" imperfections.'"^

Given the disintegration of older social relations and the
increasing fear of working-class revolt — both products of capital-
ist industrialization — it is not surprising that wealthy men and
women supported the goals and programs of the charity organiza-
tions and the social work movement. Charles Hull, who amassed
a fortune from Chicago's booming real estate market, gave freely
to social rehabilitation programs in the slums and sold cheap land
to the poor to give them a stake in the existing society. It was his
way of correcting the unequal distribution of land out of which he
feared "discontent and revolution will come."'^

Scorning pity and indiscriminate relief as merely reinforcing
the poor in their degraded condition, the charity organization
movement, social work professions, and wealthy benefactors in
general worked instead to uplift, or rehabilitate the poor. They
established institutions that would isolate "the poor that can't
work" and prevent them from infecting "honest," hard-working

"Wholesale Philanthropy" I 23

poor folk. They also developed programs to give the working
poor a loftier vision of life than could otherwise be gotten from
the factories and tenements in which they spent their lives.
Settlement houses and social workers were established in the
slums and ghettos to integrate the foreign-born into American
society and to rehabilitate and reintegrate the casualties of an
industrial society divided into owners and nonowners. Jane
Addams' settlement house, provided by Charles Hull's estate,
attempted to fulfill her principal goals to "feed the mind of the
worker, to lift it above the monotony of his task, and to con-
nect it with the larger world outside of his immediate sur-
roundings. ..." Addams opposed the excesses of both capital
and labor and worked to bring together these warring classes
through programs acceptable to both.'^

Such programs did not suggest that the capitalist social
structure itself should be altered. Rather they were intended to
ameliorate the harsh conditions of capitalism by helping individu-
als escape from its pits and lead both useful and more satisfying
lives. While many social workers supported union demands, their
work won financial and political support from the wealthy classes
because it diverted attention from more militant demands. Social
workers held out the hope of ameliorating Hving conditions with
social programs while workers demanded union recognition,
higher pay, the eight-hour day, and relief from unemployment.
All these programs proved more symbolic and ideological than
actually ameliorative. The working poor and the unemployed
were being taught to blame their own inadequacies for their
conditions and to work and wait patiently for their individual
rewards.

Some capitalists, however, both before and after the Civil
War, were less concerned with revolt brewing below them or
were more thoughtful about the future needs of their social
system. They developed another line of philanthropy that
centered on creating social institutions whose main functions
were not even symbolic amelioration but provided for the
training of personnel needed by industrial capitalism if it was to
survive and grow. Some of these capitalists, particularly in the
first half of the nineteenth century, helped to create compulsory
pubHc schooHng to socialize working-class and poor children to
the rhythms and cooperative needs of factory work and to give

24 I ''Wholesale Philanthropy"

them the rudimentary skills — reading, writing, arithmetic, and
vocational skills — needed in an industrial society. ^° Other men
and women of wealth understood the country's need for more
advanced technical skills. They joined forces with foresighted
leaders of the nation's traditional colleges, bringing them out of
the orbit of the old agricultural and merchant ruling class and into
the service of the ascending industrial and financial order.

TRAINING SCIENTIFIC HEADS TO DIRECT
AMERICA'S "HARD HANDS"

On the last day of April in 1846 Edward Everett, the new
president of Harvard University, stood before his faculty,
students, and alumni and inaugurated a new era of cooperation
between industrialists and America's colleges and universities.
Harvard would no longer be geared mainly to the needs of the
agricultural gentry and wealthy merchants, producing educated
clergy, lawyers, and assorted gentlemen. Everett laid before his
inaugural convocation a proposal, that Harvard found a "school
of theoretical and practical science" to teach "its application to
the arts of life," to furnish a "supply of skillful engineers" and
other persons who would explore and develop the "inexhaustible
natural treasures of the country, and to guide its vast industrial
energies in their rapid development."^^

Within a year Abbott Lawrence agreed to underwrite Ever-
ett's plans. Lawrence's investments in textile manufacturing and
railroad financing had made him a man of wealth and influ-
ence in Massachusetts. The industrial revolution in America was
in its infancy when he began, but now near midcentury its
potential was proven. Lawrence knew first hand the value of the
factory system and mechanization in increasing production and
profits. He saw that railroad construction brought not only profits
on his investment; it also created a demand for iron production
and opened up regional and national markets, allowing farmers
and factory owners to ship their products to distant markets and
increasing America's exports. "Hard hands are ready to work
upon our hard materials," he observed. But "where shall
sagacious heads be taught to direct those hands?"^^

To answer his own question and help Harvard realize its
self-appointed role, Lawrence gave the university the then

"Wholesale Philanthropy" I 25

princely sum of $50,000 to found a school that would apply
chemistry and other sciences to the needs of agriculture, engi-
neering, mining and metallurgy, and the "invention and manufac-
ture of machinery." Thus was the Lawrence Scientific School
born. Lawrence was so pleased with the new school that he
bequeathed an additional $50,000 for it which Harvard received
upon his death in 1855.

Harvard's school was exemplary of the new relationship
between science, education, and industrialization. In the nine-
teenth century, scientists, industrialists, and college presidents
developed a profitable alliance. The usefulness of science to
industry, the willingness of industrialists to support scientific
research, and the opportunity for colleges to train scientists and
engineers and do much of the research needed by industry
provided a great deal of common ground. It also opened the door
for scientists who wanted to make science a full-time occupation
and distinguish themselves from others who used the knowledge
and methods of the natural sciences in their work.

The great inventors of the early industrial revolution were
mostly practical-minded mechanics, craftsmen, and tinkerers,
men and women whose lives embraced science through their
work. "In contrast with modern practice," observes Harry
Braverman, "science did not systematically lead the way for
industry, but often lagged behind and grew out of the industrial
arts."" By the 1830s and 1840s a new group of scientists emerged
who wanted to be more than "dilettantes." Like their European
counterparts, whose support and status they envied, the upper
ranks of American scientists wanted to devote themselves to
research, but they lacked the necessary financial resources.
Although young men in America's colleges were taught science,
there was almost no original research being done in the country.
As Joseph Henry, the nation's leading physicist, complained,
"every man who can burn phosphorous in oxygen and exhibit a
few experiments to a class of young ladies is called a man of
science."^"*

In 1844 Alexander Dallas Bache, the superintendent of the
U.S. Coast Survey, told an attentive audience at the country's
first national scientific congress that America's unoriginal and
meager science merely aped European science. America's sci-
ence, he said, had inadequate institutional support, substituted

26 I "Wholesale Philanthropy'

teaching for scientific research, was overrun with gentleman
scientists, and lacked professional scientists. Bache and Henry,
together with Harvard mathematician Benjamin Peirce, astrono-
mer Benjamin Gould, chemist Oliver Wolcott Gibbs, zoologist
Louis Agassiz, and a few other professional scientists fancied
themselves the nation's sole custodians of science and its develop-
ment. They aggressively sought support for their research and
promoted the cause of professional science. In their view, only
some men were endowed with scientific talent, and only such an
elite should be entrusted with training, facilities for research, and
money. As Howard Miller has pointed out, their eHtism won
them no support from the assertive, democratic populists of
Andrew Jackson's era."

These new men of science won increasing support from the
entrepreneurial fortunes of the captains of industry. Lawrence
was neither the first nor the last capitalist of the nineteenth
century to channel his surplus wealth to colleges in order to put
science at the service of industry. In 1846, with the financial help
of philanthropists, Yale created two new professorships in
agricultural and practical chemistry and appointed the eminent
Benjamin Silliman, Jr., to one of them to develop and teach the
"application of chemistry, and the kindred sciences to the man-
ufacturing arts, to exploration of the resources of the country
and to other practical uses." Silliman's prolific accomplishments
at Yale included developing the first commercially successful
method of refining petroleum. Before the Civil War, Joseph Earl
Sheffield, a New Haven man who made his fortune in Southern
cotton and in financing Northern railroads and canals, gave the
strugghng Yale Scientific School a large contribution. The
university appreciatively renamed the school in honor of its
benefactor, whose contributions to Yale for applied science
totaled more than $1 million by the time of his death in 1882.^*

Perhaps the most symbolic change was the conversion of the
Reverend Nathan Lord, president of Dartmouth College. As he
assumed the college presidency in 1828, Lord asserted that
Dartmouth was not designed for men who were to "engage in
mercantile, mechanical, or agricultural operations." His strict
adherence to the classics and to preparing gentlemen, however,
did not survive several large contributions from wealthy advo-
cates of appHed sciences and engineering. By the late 1860s Lord

"Wholesale Philanthropy" I 27

eagerly embraced the "necessity now becoming constantly more
evident of a higher education in the 'practical and useful arts of
life.' "^'

Some industrialists and finance capitaHsts, not content with
the slow and incomplete transformations of the older colleges,
started their own engineering schools. In 1824 Stephen Van
Rensselaer, a wealthy landlord farmer who organized and backed
the construction of the Erie Canal and thereby experienced for
himself the lack of adequately trained engineers, founded the
institute that bears his name to teach the "application of experi-
mental chemistry, philosophy and natural history, to agricul-
ture, domestic economy, the arts and manufactures."^* Other
engineering and technical schools were begun around the country
from fonts of industrial wealth — Cooper Union in New York
City, the Massachusetts Institute of Technology, the Stevens
Institute in Hoboken, the Case School of Applied Science in
Cleveland, the Pratt Institute in New York, and the California
Institute of Technology, to name a few.

Philanthropic capitalists left their marks in American higher
education in other areas besides science. Joseph Wharton, a
wealthy manufacturer of metals, gave the University of Pennsyl-
vania some $600,000 for a school of finance and commerce that
would train the managers, accountants, and leaders of industry
who would direct the engineers and appHed scientists graduating
from technical schools. Entirely new universities were founded in
the 1870s and 1880s by some of the wealthiest men and women in
the country — ^Johns Hopkins, Tulane, Clark, Vanderbilt, Stan-
ford, Cornell, and others.

These educational philanthropists were primarily capitalists
who disdained the aristocratic pretenses of gentleman farmers
and the dabblers' and merchants' ignorance of technique. Re-
membering their own lack of preparation as they began their
careers, they favored practical educations that would promote
endeavors like theirs and create a fertile ground from which their
new society would grow. They also perceived a need for trained
personnel for the growing industrial and corporate economy. As
the organizers of factories and other enterprises that employed
increasing divisions of labor, they preferred to train technically
skilled managers and reduce the skill levels of their laborers; in
the words of Abbott Lawrence, let the "hard hands" do the labor

28 I "Wholesale Philanthropy''

and let "sagacious heads" design and direct the labor process.
Impressed with the utility of applied science, they subsidized
teaching and research in the natural sciences and engineering,
and they supported vocational and applied curricula in colleges
against the prevailing classical education. By the end of the
century they were delighted with the progress that had been made
in creating universities and colleges in their own image. And, of
course, they were glad to have combined this self-interest with an
appearance of generosity and altruism.

The entrepreneurial scientists and college presidents made the
philanthropists' job an easy one. The development of modern
universities and the founding of professional science in the
United States were largely the products of elite college presidents
and men of science inviting captains of industry to recognize the
importance of their contributions to the nascent industrial and
corporate society. They asked for and got money for their work,
their institutions, and themselves.

Scientists offered their talents and their services to the
capitalists in return for new laboratories and stipends; they gave
up to the colleges a degree of autonomy in return for a legitimized
base of operations, some financial security, and a protected role
in training new basic and applied scientists as well as conducting
research. College presidents acted as brokers, eagerly offering
their services and institutions to capitalists and scientists alike, in
return for new areas of service that would assure the continued
relevance and financial security of their institutions under the
ascending economic order. Their new buildings and endowments
assured them that they were on the right track. By 1872
philanthropy accounted for nearly half the $13 miUion income
received by all the nation's institutions of higher education. ^^

The founding of schools, institutes, and universities was quite
a different tack from giving to charity organization societies and
creating settlement houses. They were both intended to meet the
needs of the developing industrial and corporate society, but in
different ways. One was ameliorative: It tried to compensate for
the failings of the capitalist social structure. The other was more
technical and "preventive": Institutions were developed to meet
the needs of the system for technical expertise and industrial and
social management. Both were important to the survival and
expansion of industry as it was organized in capitalist society.

"Wholesale Philanthropy" I 29

There were limitations, however, in the resources and strate-
gies of both approaches. The social work approach was ameliora-
tive at a time when most philanthropists were pressing for
preventive strategies. The founding of universities and institutes,
which had a preventive character, was limited in two ways. First,
it often represented an individual action on the part of a
particular rich man or woman who founded the institution to
reflect a personal perspective of what was needed. While some of
them secured the help of visionary university presidents, these
institutions often reflected too strongly the personalities and
idiosyncratic views of their founders. Only when governance fell
to the institution's trustees did it come to reflect a broader
perspective within the benefactor's class. Thus, the trustees who
implemented Johns Hopkins' bequest for the founding of a uni-
versity were able to do what they collectively believed worth-
while because their broad charter left them free of detailed
instructions from the deceased benefactor while the endowment
meant they had "no need of obeying the injunctions of any
legislature, the beliefs of any religious body, or the clamors of any
press. "^° Most benefactors, especially those who founded their
institutions while on this side of their graves, held closer reigns on
policies and personnel.

The second Hmitation on the usefulness of the university
movement among the wealthy was one of scale. Most of the
founders had fortunes big enough to create only one institution,
and those who had the wealth to do more nevertheless concen-
trated their energies and their money in one place. Thus their
direct influence would come from only one place, and their
indirect influence would be only as a model. These were often
powerful forces. Van Rensselaer's institute claimed, by the
middle of the nineteenth century, that it had produced a majority
of the country's engineers and naturalists. And the class of
wealthy university founders was small and often influenced each
other: Ezra Cornell's new university at Ithaca was admired by
Leland Stanford, and Stanford's creation in California greatly
impressed Jonas Clark and his plans for Massachusetts.^' These
exceptions notwithstanding, the general limitations of individual-
ism and narrowness of resources reduced the utility of university
building for corporate capitalism.

The accolades these "good works" generated didn't mean that

30 I ''Wholesale Philanthropy"

philanthropy could not be done better. And certainly the cap-
italist impulse to believe in perfectability in the organization of
any enterprise encouraged many philanthropists to look for errors
and seek a better way. The obvious constraints of ameliorative
social intervention programs drew most of the criticism. But
while the create-a-school movement was not criticized explicitly,
a successor was soon seen on the horizon. At best the univer-
sities were productive models of capitalist rationality and tech-
nical modernness in an untamed, competitive marketplace of
seemingly incompetent educational institutions. Not surprisingly,
it was the philanthropies created by the kings of oil and steel
that started American schooling down the same road to vertical
organization and centralized control that they had created in
their own industries.

CARNEGIE'S "GOSPEL OF WEALTH"

The growing fortunes of the Carnegies and Rockefellers in
this country made them prominent symbols of the success as well
as the inequities of industrial capitaHsm. It was this weighty
responsibility that led Andrew Carnegie to explain the problems
associated with great wealth and to lay out the responsibilities
that came with its possession. In an influential two-part essay
entitled "Wealth," published in the North American Review in
1889,^^ Carnegie with a flush of confidence set out a plan for
assuring continued private accumulation of wealth. "The prob-
lem of our age," he boldly began, "is the proper administration of
wealth, that the ties of brotherhood may still bind together the
rich and poor in harmonious relationship." Speaking to a
receptive audience among the "haves" more than to the truculent
"have-nots," Carnegie identified the accumulation of wealth as
the essential factor in the "progress of the race." Whether it be
"for good or ill, it is upon us, beyond our power to alter, and,
therefore, to be accepted and made the best of. It is a waste of
time to criticize the inevitable," he reassuringly added.

Though capitalism's "law" of competition "may be sometimes
hard for the individual, it is best for the race because it insures
the survival of the fittest in every department," he observed,
paraphrasing the then widely idolized Herbert Spencer. Further-
more, it produced great material wealth so that all people lived
better for it. Society must not only accept; it must welcome "great

"Wholesale Philanthropy" I 31

inequality of environment," specifically the "concentration of
business, industrial and commercial, in the hands of a few." It is
not to be regretted that capitalists must "soon be in receipt of
more revenues than can be judiciously expended upon them-
selves." It is simply incumbent upon the wealthy to dispose of
their fortunes wisely.

They should not, he warned, leave the bulk of their wealth to
their families, for such legacies undermine the moral integrity of
the recipients. Nor should the rich man simply bequeath his
fortune for public purposes because it is morally reprehensible to
accumulate great wealth and not show either the interest or the
judgment to spend it wisely. As exciting as Carnegie found his
money-making career, it had always seemed to him below the
moral and intellectual world to which he aspired. More than two
decades before his declarations on wealth, Carnegie had written a
memo to himself promising to quit business shortly: "To continue
much longer overwhelmed by business cares and with most of my
thought wholly upon the way to make more money in the shortest
time, must degrade me beyond hope of permanent recovery.""
Now Carnegie admonished his peers, "The man who dies thus
rich dies disgraced."

It is the duty of the wealthy, Carnegie declared in his article,
"to consider all surplus revenues which come to him simply as
trust funds," to do what, "in his judgment," is best for the
community. The wealthy capitalist is thus a "mere trustee and
agent for his poorer brethren, bringing to their service his
superior wisdom, experience, and ability to administer" — in a
word, "doing for them better than they would or could do for
themselves."

He then recommended to men and women of substantial
means seven uses for their surplus wealth, declaring the priorities
that he followed in the years to come. Topping the list were
universities, to which Carnegie gave more than $20 million in his
lifetime. Next were free public Ubraries, which, to Carnegie's
mind, squared with his goal "to stimulate the best and most
aspiring poor of the community to further efforts for their own
improvement." Carnegie contributed 2,811 libraries to communi-
ties that promised to support them; this most famous of his
philanthropies consumed more than $60 million of his wealth.
Carnegie also recommended giving money for medical institu-
tions, public parks and city beautification, halls for "concerts of

32 I "Wholesale Philanthropy

elevating music" and enlightening lectures, swimming baths,
and — last — church buildings. ^"^

Carnegie's round face glowed and his eyes sparkled as he
received the adulation of wealthy admirers and fawning suppli-
cants. Gladstone sanctified Carnegie's proposals with a review of
his article in the prestigious British magazine Nineteenth Century,
criticizing only Carnegie's condemnation of inherited wealth.
From his celebrated position, Carnegie dismissed the critical
reviews of his article. The Reverend Hugh Price Hughes, a prom-
inent Methodist minister and Christian populist, condemned
this new "Gospel of Wealth," as it had come to be called. "Mr.
Carnegie's 'progress' is accompanied by the growing 'poverty'
of his less fortunate fellow-countrymen," he wrote. William
Jewett Tucker, a Uberal theologian and later president of Dart-
mouth College, pointed out that the assumption "that wealth is
the inevitable possession of the few, and is best administered by
them for the many, begs the whole question of economic justice
now before society." "I can conceive of no greater mistake,"
Tucker protested, "than that of trying to make charity do the
work of justice. "^^

Carnegie's giving never aimed at justice; his goal was "to lead
people upward." Like his politics, Carnegie's philanthropy was a
mixture of moraUstic programs to civilize the masses, impulsive
decisions, and sentimentaHty. Libraries, institutes, concert halls,
and church organs — 7,689 organs costing more than $6 million —
were given to uplift the poor and working classes. In 1904 he
provided more than $10 miUion for the Carnegie Hero Fund to
honor men and women who are injured or killed while trying
to save their fellows; medals were presented to the hero, or his
or her surviving family, and occasionally monetary grants, to
encourage the masses to follow examples set by "the heroes of
civilization." Carnegie also provided his birthplace of Dun-
fermline, Scotland, with a $3.75 million fund for parks, recrea-
tion, and general beautification.^^

REVEREND GATES INTRODUCES ROCKEFELLER
TO "WHOLESALE PHILANTHROPY"

Like Carnegie, John Davison Rockefeller's interest in finan-
cial benevolence antedates his most famous philanthropies. From
the time of his youth. Rockefeller's life consisted of work, family,

"Wholesale Philanthropy" I 33

and the Baptist church. More like his pious mother than his genial
and impulsive father, Rockefeller lived a disciplined life, forever
pinching pennies but mindful of his Christian duties. Even in
1855, when he was earning $3.50 a week as a clerk accountant in
Cleveland, Rockefeller carefully apportioned about 10 percent of
his income to charities and church work. His philanthropy grew
with his riches; by 1881 he was giving away more than $60,000 a
year.^^ By the end of the century, he and Carnegie were com-
peting in their philanthropy — with Carnegie ahead.

Rockefeller was diligent in giving to charity but ungenerous in
spirit. Like other men of his day climbing the ladders of business
success and those who had reached the top. Rockefeller saw no
excuse for poverty. Having gone into business for himself at the
age of twenty, the oil king "knew" that hard work and discipUned
living were the means to escape poverty. In 1887 Rockefeller
answered a poor young man's plea for fifty dollars with a check, a
request for an I.O.U. , and a warning: "It will be injurious for him
to receive from others what he can in any way secure for himself
by his own efforts." And after a visit to a "house of industry" in
New York's incomparable slum of Five Points, he complained
that although the institution gave free meals to the area's
"tramps" only on Thanksgiving Day, he "would give them work
and make them earn their food."^^

Whereas Carnegie's secular views led him to Social Darwin-
ism as a biological and social explanation for the maldistribution
of wealth, Rockefeller's religion exorcised all self-doubts. Partic-
ularly as he grew older and more comfortable with his fortune
and his role as philanthropist, Rockefeller came to believe that
"God gave me my money." When he uttered these words in 1905,
"Rockefeller" was not the most revered name in North America.
He thus felt called upon to explain: "I believe the power to make
money is a gift from God ... to be developed and used to the
best of our ability for the good of mankind. I believe it is my duty
to make money and still more money and to use the money I
make for the good of my fellow man according to the dictates of
my conscience. "^^

Rockefeller's conscience led him to heap great benevolence
on a wide range of socially uplifting charities. Andrew Carnegie
put churches last on his list of recommended philanthropies, but
for Rockefeller the Baptist church and its numerous charities and
missions were the highest priority. Hospitals and other public

34 I ''Wholesale Philanthropy'

welfare charities were also favorites. He hoped his contributions
would enable the denomination to lead all people to live with
rectitude and to aid the fallen poor to gain the proper path. In
1890 Rockefeller's contributions to charities and colleges topped
$300,000, and the next year half a million dollars.

But in May 1889, one month before Carnegie published the
first of his two-part "Gospel of Wealth," Rockefeller committed
himself to a particularly ambitious philanthropic project and a
relationship with a man who was to write a new chapter in
philanthropy. For several years a group of Baptists in the East
and another group in the West had been trying to develop a new
seminary and university for the denomination. The eastern group
wanted the institution to be located in New York while the other
group desperately hoped to develop it in Chicago, the rapidly
growing metropolis of the nation's westward expansion. Both
groups were pressing Rockefeller, the richest Baptist in the
world, to contribute the millions needed to endow a first-rate
institution. While interested in such a project, Rockefeller was
not swayed by the emotionalism of either group's appeal. "^^

The strugghng academies, seminaries, and colleges of the
denomination met in Washington in May 1888 to form the
American Baptist Education Society, to raise money for Baptist
education, and to coordinate its development. They named the
fast-rising Reverend Frederick T. Gates executive secretary, a
position from which he leaped to the pinnacle of both philan-
thropic and corporate power.

Gates immediately conducted a survey of Baptist educational
needs throughout the country. Armed with his data, he wrote a
detailed and eloquent report. Gates demonstrated that nearly
half the country's Baptists lived west of Pennsylvania and north of
the Ohio River but that the denomination's educational facilities
in this region were practically worthless. He concluded that a new
Baptist university should be built "on the ruins of the old
University of Chicago," a weak and by then bankrupt denomina-
tional institution. While the new university should bring together
the most capable specialists in both its classical and scientific
departments, it must be "an institution wholly under Baptist
control as a chartered right, loyal to Christ and His church,
employing none but Christians in any department of instruction,
a school not only evangelical but evangelistic.'"*'

Gates' report was the turning point in the denomination's

''Wholesale Philanthropy" I 35

campaign for a university. As he himself put it, "The brothers
were 'all torn up' over it." The Chicago proponents coalesced
around the report, and the dwindhng supporters of a New York
location became even more emotional in their desperate appeals
to Rockefeller. The Education Society executive board unani-
mously approved the proposal at the December 1888 meeting.
Within six months Gates won Rockefeller's approval and an
initial gift of $600,000 that soon became a torrent of support,
totaling $35 million in the next twenty-one years. Rockefeller was
so impressed with Gates that he wrote University of Chicago
president Harper in 1889, "I have made up my mind to act in my
educational benefactions through the American Baptist Educa-
tion Society. '"^^

Rockefeller, worn out by his total immersion in business since
the age of twenty, was a physical wreck as he entered his fifties in
1889. He suffered increasingly from nervous fatigue and stomach
ailments. He soon lost all his hair, including his eyebrows,
because of a nervous disease, generalized alopecia. His doctors
had warned him to reduce his activities as much as possible, but
his responsibihties were mounting. Although Standard Oil was
now in the hands of experienced and trusted lieutenants, there
was an increasing flow of requests for large and small portions of
his wealth from churches, missionary societies, hospitals, colleg-
es, charity organizations, and individuals — once running as high
as 50,000 requests in a single month. "^^

In March 1891 Rockefeller sat Gates down and laid out his
problem.

I am in trouble, Mr. Gates. The pressure of these appeals for gifts
has become too great for endurance. I haven't the time or strength,
with all my heavy business responsibilities, to deal with these
demands properly. I am so constituted as to be unable to give away
money with any satisfaction until I have made the most careful
inquiry as to the worthiness of the cause. These investigations are
now taking more of my time and energy than the Standard Oil itself.
Either I must shift part of the burden, or stop giving entirely. And I
cannot do the latter.'*'*

"Indeed you cannot, Mr. Rockefeller," replied Gates, listen-
ing with great care and at the same time anticipating the
benefactor's point.

"Well, I must have a helper," Rockefeller continued. "I have

36 I "Wholesale Philanthropy"

been watching you. I think you are the man. I want you to come
to New York and open an office here. You can aid me in my
benefactions by taking interviews and inquiries, and reporting the
results for action. What do you say?"

Fervently aware of the wealth and power that would rest in his
hands to use on behalf of all the things he believed important,
Gates accepted without the slightest hesitation. He thus began a
relationship with Rockefeller that transformed the world's larg-
est fortune into the most strategically applied philanthropy,
estabhshing principles, methods, and directions that were soon
emulated by other philanthropists and continued through the
next two generations of the Rockefeller dynasty. The numerous
medical and public health programs would become the central
part of Gates' strategy.

In September 1891, Gates took an office in the Temple Court
Building in New York City, not far from Rockefeller's Standard
Oil offices at 26 Broadway. He continued his work for the
Education Society even while he took charge of Rockefeller's
philanthropy. The supplicants who hounded Rockefeller "almost
like a wild animal" were sent to Gates' office. "I did my best to
soothe ruffled feeUngs, to listen fully to every plea, and to weigh
fairly the merits of every cause," Gates recalled of his days at
Temple Court. "^^

With the same systematic thoroughness that marked his
report for the Education Society, Gates investigated each request
that came his way. "I found not a few of Mr. Rockefeller's
habitual charities to be worthless and practically fraudulent. But
on the other hand I gradually developed and introduced into all
his charities the principle of scientific giving, and he found
himself in no long time laying aside retail giving almost wholly,
and entering safely and pleasurably into the field of wholesale
philanthropy.'"^^

Gates' first act on behalf of "wholesale philanthropy" was to
increase Rockefeller's contributions to state and regional Baptist
agencies and cut off contributions to individual churches, mis-
sions, and charity organizations. By forcing every church and
mission to get their aid from centralized denominational boards,
Gates increased the latter's power over the far-flung flock.'*''

Not long after he moved to New York, Gates took charge of

"Wholesale Philanthropy" I 37

Rockefeller's many investments outside the Standard companies.
As with his charities, Rockefeller always intended to check on his
investments thoroughly before buying into them. Often he was
persuaded by acquaintances to invest in a project or industry they
assured him would pay off handsomely. Most of the immense
"surplus" wealth that Rockefeller was taking out of oil he was
putting, not into charity, but into "a good many different in-
dustries." By 1893 he had accumulated, besides the Standard,
sixty-seven major investments, valued at $23 million, in railroads,
mining, manufacturing, and banks. "It occurred to me," Rocke-
feller later recalled, "that Mr. Gates, who had a great store of
common sense, though no especial technical information about
factories and mills, might aid me in securing some first-hand
information as to how these concerns were actually prospering."
He asked Gates to investigate some of these investments when he
happened to be in the area on Education Society business."^*

Gates checked on several of Rockefeller's distant stakes: an
immense land speculation scheme in the Pacific Northwest that
two fellow parishioners of Rockefeller's Fifth Avenue Baptist
church had persuaded the oil baron to invest in; a $600,000
investment in a West Superior, Wisconsin, steel mill and land
speculation fraud, recommended by the same brethren; and a
smaller iron furnace in Alabama. Gates demonstrated his varied
abilities and singular value to his employer. "His report was a
model of what such a report should be," Rockefeller remarked
with uncharacteristic praise. "It stated the facts, and in this case
they were almost all unfavourable." One investment that Rocke-
feller thought was earning $1,000 a day was instead losing that
amount.'*^

One more investigation by Gates, of some reputedly rich gold
mines in Colorado that turned out to be a complete fraud, settled
the matter for Rockefeller. His income was now upwards of $10
million a year, he was physically and emotionally coming apart at
the seams, and he desperately needed a heutenant in whom he
could place complete confidence. He asked Gates to drop his
office in the Temple Court Building and share his private offices
at 26 Broadway. "That," wrote Gates, "is how I came to be a
businessman. "^°

38 I ''Wholesale Philanthropy"

THE REVEREND FREDERICK T. GATES:

THE MAKING OF A ROCKEFELLER MEDICINE MAN

It is not surprising that Gates should be such an appeahng
assistant in both philanthropy and finance. Although he graduat-
ed from the Baptist-controlled Rochester University and the
Baptist seminary in Rochester and then spent eight years in the
ministry, Gates was at heart a businessman in spiritual clothing.
As he himself said in his autobiography,

Much of my life has been in fact an unconscious preparation for
successful business. My interesting experience in selling harrows,
my months as a clerk in a country store, and as cashier of a country
bank, my interest in my father's financial affairs and the ways and
means of paying our debts, my studies of political economy under
Doctor Anderson [at Rochester], my close study of the finances of
our church building in Minneapolis, a habit of looking at things in
their financial tendencies and relations, my study of denominational
finances at home and abroad, all these things had given me a
business experience and my mind a financial turn.*'

Gates was nearly thirty-eight years old when he went to work
for Rockefeller. His early years were spent in rural poverty. His
father had studied medicine but turned to the Baptist ministry for
his life's work. The elder Gates' successive congregations were
mainly poor farmers in rural New York; his family shared that
poverty which bred at least part of Frederick's determination to
leave it behind in his own life. When the family moved to Forest
City, Kansas, Frederick began but had to quit high school and
then taught school to earn money to help his family pay off the
accumulating debt on their farm." Through high school and
college jobs Gates worked with his characteristic diligence and
energy and discovered how much he pleased his employers. His
shrewd salesmanship earned him $1,500 for selling harrows.
Gates was developing a sense of where his ambition might
eventually take him.

Young Gates' experiences with religion were as important in
shaping his future life as were his experiences with poverty. "The
best that religion had to offer me as a boy," he wrote near the end
of his life, "was death and heaven, the very things I most
dreaded — being a normal, healthy boy." With his teaching job

"Wholesale Philanthropy" I 39

Gates developed a strong attraction to the intellectual and
personal elements of religion, though his conversion was not an
emotional one. He found Christ's social and moral teachings very
attractive: "I was drawn to his person and character, and feh that
throughout my life I wanted to side with him and his friends
against the world and his enemies. Such, frankly, was the only
'conversion' I ever had."

He found his seminary training so academic as to leave him
poorly prepared for ministerial work. He dispensed with the
philosophical idealism the seminary had cultivated, and from his
own reading, his life experiences, and examination of the econ-
omic and social issues affecting his congregation. Gates took
up a pragmatic philosophy that was more in keeping with his
personality and his ambition. His fund-raising work for his poor
parish in Minneapolis and his less solemn, more modern sermons
attracted a bigger congregation and with it, more wealth.

One day George Pillsbury, whose flour fortune made him the
wealthiest Baptist in the Northwest, asked Gates' advice in
making up his will and especially in leaving $200,000 to a Baptist
school. Pillsbury was very pleased with Gates' suggestion that he
immediately give $50,000 to the school on the condition that the
denomination in Minnesota raise an equal amount — to assure
their committed interest in it — and that he bequeath another
$150,000 to the school in his will. Baptist leaders were also
pleased and commissioned Gates to raise their $50,000 share of
the funds. Gates resigned his pastorate and took up the chal-
lenge. So effective were his methods of button-holing Baptists in
the state that he had soon raised $60,000." Gates knew he had
found his calling!

He developed a number of rules for fund raising which he
learned "mostly on the pastorate" and a couple of years later
wrote them down at the request of his admirers in the trade.
Dress well, act in a dignified manner, pretend the visit will be a
short one, be good-natured, and "keep your victim also
good-natured. . . . Let him feel that he is giving it, not that it is
being taken from him with violence." Rule number 7 he followed
unswervingly through his nearly four decades of service to
Rockefeller: "Appeal only to the noblest motives. His own mind
will suggest to him the lower and selfish ones. But he will not wish
you to suppose that he has thought of them. He wishes you to

40 I "Wholesale Philanthropy

believe him to be giving only from the highest motives."^"* In a
few years Gates rose from pastor of an average Baptist congrega-
tion in Minneapolis, to a statewide position with the denomina-
tion in Minnesota, to chief officer of the Baptists' national
Education Society, to the side of Mr. Rockefeller himself,
administering a panoply of investments and an immense philan-
thropy.

As soon as he joined Rockefeller's private office to manage
his finances. Gates began a meticulous evaluation of all Rockefel-
ler's holdings outside the Standard Trust. He was given a free
hand in reorganizing investments and corporations alike and was
provided with assistants, credit, and confidential information. "I
had every needed tool," Gates remembered, "and the machinery
was well oiled and without the least friction. No man of serious
business responsibilities ever had a happier business life than I.
No man was ever furnished with more of the external elements of
success, or given better opportunities." In some companies Gates
bought enough stock to take control and put in management
acceptable to him and Rockefeller. Other investments were sold
off completely. In the end. Gates was made president of thirteen
corporations in which Rockefeller now had a controlling interest.
He added sizeable chunks to Rockefeller's geometrically increas-
ing fortune, the grandest chunk being the $55 million profit Gates
made on selling the Mesabi iron ore range and associated
industries that he had developed. ^^

Although Gates came to Rockefeller's employment a poor
man, he soon remedied this unfortunate condition. While
executive secretary of the Baptist Education Society, Gates was
paid a then-respectable income of $2,500 a year. When he moved
East and opened an office in the Temple Court Building,
Rockefeller added $1,500 to his income. His added responsibili-
ties led to annual increases in salary "always paid by the
corporations which I managed," until after ten years with
Rockefeller he was getting a salary of $30,000, a very good
income in the first decade of this century. Out of his earnings
Gates and his wife had saved enough to pay for their Montclair,
N.J., home and had invested some $60,000 in the companies he
had organized and managed for Rockefeller. That small invest-
ment brought him more than $500,000 when he sold his shares in
1902. "Prudent investments with few losses gradually increased

''Wholesale Philanthropy" I 41

this sum." In 1916 Gates began converting all his investments into
then-rising and profitable bank stocks and encouraged Rockefel-
ler to do the same, recommending especially the Chase National
Bank, which was paying dividends of 20 percent on invested
capital. By the time of his death in 1929 Gates was a wealthy man
though, needless to say, his fortune fell far short of his employ-
er's.^^

Though Rockefeller never paid direct compliments to any
person, he more than once recorded his appreciation of Gates'
"phenomenal business ability." In response to a reporter's
question, "Who is the greatest of all the business men you have
known?" Rockefeller heaped warm praise on Gates. "He
combines business skill and philanthropic aptitude to a higher
degree than any other man I have ever known. "^"^ Though Gates
was involved with Rockefeller's finances in important ways, his
organization of Rockefeller's philanthropies, and especially the
medical programs, makes him historically significant.

In 1897, John D. Rockefeller, Jr., graduated from Brown
University and was cautiously trying to find a place for himself in
a world preempted by his father. His hereditary position in the
world of industry and finance left him little room for any
achievement that he could call his own. His own name was
inseparable from his father's, who was perhaps the most vilified
of all the great robber barons. The one area in which he might
stake out new ground and at the same time help clear the family
name was philanthropy. And thus he entered his father's private
offices at 26 Broadway, an imperium presided over by the
Reverend Gates. ^^

With difficulty Gates and "Mr. Rockefeller, Junior" devel-
oped a working relationship. Junior was then twenty-three years
old, inexperienced, and reserved to the point of shyness. Gates,
twenty years his senior, did not hide his self-confidence derived
from varied experience and personal achievement; he was
ebullient. Nevertheless, Junior learned from Gates and from his
own successes and failures and built an independent role for
himself in both philanthropy and finance. For his part, Gates
learned to tolerate this scion of the man he worked for and truly
respected. Gates considered Junior "diligent" but unimaginative.
"He was home-made and hand-trained," he recalled disdainfully.
Rockefeller, Sr., had found, as his biographer Allan Nevins

42 I "Wholesale Philanthropy"

observed, "just the combination of qualities he needed: Gates
endowed primarily with imagination, fire, and vision, the son
endowed primarily with hard sense, caution, public spirit, and
conscientiousness."^^

Gates and Junior investigated new lines of philanthropy and
the value of Senior's investments, bringing major proposals for
action on both to the financier for final decisions. Gates wrote
his views in eloquent reports; Junior relied on oral persuasion.
"Gates was the brilliant dreamer and creator," Junior recalled
years later. "I was the salesman — the go-between with Father at
the opportune moment." Senior seldom jumped into any new
venture. "I'll let the idea simmer," he often told his son and
Gates. Then weeks, months, or even years later, moved by
considerations inscrutable to his assistants, he was ready to act.^°

Gates was also quite a contrast to his employer. As Raymond
Fosdick, president of the Rockefeller Foundation for more than a
decade, revealed:

Mr. Gates was a vivid, outspoken, self- revealing personality who
brought an immense gusto to his work; Mr. Rockefeller was quiet,
cool, taciturn about his thoughts and purposes, almost stoic in his
repression. Mr. Gates had an eloquence which could be passionate
when he was aroused; Mr. Rockefeller, when he spoke at all, spoke
in a slow measured fashion, lucidly and penetratingly, but without
raising his voice and without gestures. Mr. Gates was overwhelming
and sometimes overbearing in argument; Mr. Rockefeller was a
man of infinite patience who never showed irritation or spoke
chidingly about anybody.

61

From this triumvirate came the influential philanthropies that
asserted extraordinary leadership in shaping the social, econom-
ic, and political order of the twentieth century. Rockefeller, the
individualistic captain of industry from the rough-and-tumble old
order that was being transformed at the turn of the century,
supplied the money but left the directing to his heutenants.
Gates, the transition figure from unbridled individualism to the
discipline of the corporation, provided systematic methods and a
rudimentary strategy for asserting corporate capitalism's needs
for supportive social institutions. Junior, emerging gradually as
the nation's foremost representative of modernism in corporate
relations with labor and the public, brought a refinement and
sensitivity to the philanthropic work being developed by Gates.

"Wholesale Philanthropy" I 43

The programs and strategies that emerged from this center of
financial power had an enormous impact, especially on medical
care and health systems in the United States and throughout the
world."

THE GENERAL EDUCATION BOARD: $129 MILLION
FOR STRATEGIC PHILANTHROPY

Gates shared Carnegie's fears that excessive hereditary wealth
diminishes individual initiative and achievement, that it saps the
participation of its bearer in the social and economic processes
that make society strong. "Your fortune is rolling up, rolling up
like an avalanche!" he warned Rockefeller. "You must keep up
with it! You must distribute it faster than it grows! If you do not,
it will crush you, and your children, and your children's chil-
dren!""

Having acquired the fortune, it fell to Rockefeller and his
associates to maintain it as a trust for the people, just as Carnegie
had advocated. "It is the duty of men of means," Rockefeller
wrote early in this century, "to maintain the title to their property
and to administer their funds until some man, or body of men,
shall rise up capable of administering for the general good the
capital of the country better than they can." In his view, neither
experiences with state and national legislatures nor "schemes of
socialism" offered any promise that "wealth would be more wise-
ly administered for the general good" than it was by its private
owners. ^'^

Since the owners of capital were mortal men, it was incum-
bent on them to provide some ongoing trust to see that their
wealth would be used wisely even after they passed from the
scene. There was nothing new in this concept as understood by
the Rockefellers as they launched their first grant-giving founda-
tion, the General Education Board, to aid Southern education.
Charitable trusts independent of the state and the church have
had legal status in Anglo-Saxon law since the "statute of
charitable uses" was enacted by Queen Elizabeth in 160L Most
of these, however, had been narrowly prescribed uses — endowing
a particular hospital, giving relief to wayward girls in Brooklyn,
and providing scholarships for young men entering mechanical
engineering at a particular college.*

65

44 I "Wholesale Philanthropy"

However, there were a few precedents that greatly influenced
the creation of the General Education Board, providing the first
of its strategic philanthropic programs aimed at transforming
major social institutions. At the close of the Civil War,
merchant-banker George Peabody provided $2 million for a
Southern education fund. The war had left the South in ruins
and its schools destroyed or otherwise defunct; a generation of
Southerners was growing up uneducated and essentially illiterate.
The Peabody Education Fund hired Barnas Sears, the president
of Brown University, to set up a grant program to help schools
that were run and generally supported by Southerners. Sears was
succeeded by Jabez L. M. Curry, a Confederate politician and
planter from Alabama, who had saved his land from confiscation
after the Civil War by swearing allegiance to the United States. ^^

The Peabody Fund set an example for John F. Slater, a textile
manufacturer from Connecticut, who endowed a $1 million fund
in 1882 to educate Southern blacks. By the end of the nineteenth
century increasing numbers of Northern businessmen and South-
ern reformers were coalescing around the need to develop
Southern schools in general and educate Southern blacks in
particular. The South was not only economically and educational-
ly undeveloped; it was the section of the country from which
militant populism still received its widest political support,
threatening the ambitions of Southern Hberal reformers and
Northern conservative businessmen who wanted to "modernize"
and industrialize the region. In 1899 these leaders organized the
first of several Conferences for Southern Education. ^^

John D. Rockefeller, Jr., was a guest at the third conference
in 1901. Robert C. Ogden, a partner of John Wanamaker and
general manager of their New York department store, chartered
a special train, dubbed the "millionaires' special" by hostile
Southern newspapers, to bring Northern businessmen on a tour
of Southern black schools and then to a conference with Southern
activists in the cause. Junior and the other guests visited the
Hampton and Tuskegee institutes and other schools and ended
their tour with a meeting in Winston-Salem. This conference
established a permanent organization called the Southern Educa-
tion Board (SEB) to raise money among Northerners, assume
formal leadership of the campaign to develop Southern schools,
and conduct propaganda on its behalf. Though the board's

"Wholesale Philanthropy" I 45

budget was low — not more than $40,000 a year — and they never
gave grants as the Peabody and Slater funds were doing, the SEB
hired agents to carry their campaign to influential Southerners
and state legislatures.^*

Like the Peabody and Slater funds, essentially combined
under the leadership of their chief agent J. L, M. Curry, the
Southern Education Board unanimously supported only "indus-
trial education" for blacks. Schools organized around this model
taught the rudiments of Hteracy and emphasized industrial and
agricultural skills, disciplined work, thrift, and right living.
Hampton Institute, whose chief trustee was Ogden and whose
principal was fellow SEB member HoUis Frissell, was the pro-
totype of industrial schools for blacks. Booker T. Washington,
an early graduate of Hampton, founded a similar school at
Tuskegee, Alabama, and became the country's chief black pro-
ponent of the graduahst strategy of racial progress. For half a
century this model of education guided the work of the move-
ment for compulsory schooling, and now it was the centerpiece of
the progressive education movement, sweeping educators and
businessmen alike into a national educational reform campaign.*^

Northern and Southern businessmen were enthusiastic. "Ev-
ery element for success exists in the South," the Manufacturers'
Record declared in support,

in raw material, in climate, in the forces of Nature, and above all, in
an abundant supply of labor, which when properly trained and dis-
ciplined will be the main reliance of the South in the future for its
prosperity. It only remains for the South to do its duty to its black
population by way of training and educating in the simple manual
trades.''"

With the support of Northern money, the industrial schools
flourished and the few genuine colleges for blacks struggled under
their less than benign neglect. The Southern Education Board
and its allies won grudging acceptance of schools for blacks from
Southern white supremacist poHtical leaders, and in return
Northern members of the SEB campaigned in the North for
acceptance of black disfranchisement and Jim Crow laws as the
best way to progress for blacks. "The white people are to be the
leaders, to take the initiative, to have the directive control of all
matters pertaining to civilization and the highest interests of our

46 I ''Wholesale Philanthropy''

beloved land," Curry, former Confederate officer and now chief
of staff of the Southern campaign, brazenly proclaimed. "This
white supremacy does not mean hostility to the Negro, but
friendship for him."^'

For John D. Rockefeller, Jr., his 1901 tour and conference in
the South were "one of the outstanding events in my life." Filled
with a sense of mission. Junior discussed the new Southern
Education Board and its program with his father. Gates, his
friend Morris K. Jessup, and Dr. Wallace Buttrick, the portly and
jovial secretary of the Baptist Home Mission Society, who also
attended the conference and was now a member of the SEB. A
small group was formed to develop an ambitious project in
support of the Southern work. In January 1902, they outlined a
munificent philanthropic enterprise. In February an expanded
group met for dinner at Junior's house and worked through the
evening. Junior announced a pledge he had secured from his
father for $1 million to spend over the next ten years, the first and
smallest of many gifts to come. They formed a board of trustees
to oversee the expenditures and appointed Buttrick executive
secretary.''^ "The South with its varied resources and products,"
their memorandum of agreement observed, "has immense indus-
trial potentialities, and its prosperous future will be assured with
the right kind of education and training for its children of both
races. "''^

The General Education Board was announced to the press.
"The object of this association," they explained, "is to provide a
vehicle through which capitalists of the North who sincerely
desire to assist in the great work of Southern education may act
with assurance that their money will be wisely used."^"*

The General Education Board (GEB), with its large re-
sources, quickly became the locus of leadership in the Southern
campaign. At its first meeting in 1901 the Southern Education
Board had arranged a "community of interest" with the Peabody
and Slater funds. By 1903, according to Southern board member
Frissell, "the Peabody and Slater boards are now acting very
largely through the General Education Board." In fact a more
interlocking directorate could not be found, even among the
Standard Oil companies. Several trustees of the Slater and
Peabody boards were trustees of the GEB. Curry was a member
or agent of all four funds. Buttrick was a member of the Southern

"Wholesale Philanthropy" I 47

board, executive secretary of the GEB, and from 1903 to 1910 he
was an agent of the Slater Fund — and so on.'''

While the General Education Board developed other pro-
grams over the next several decades, medical ones prominently
among them, their work in the South remained important and
never deviated substantially from their original perspective. Over
the years the GEB wo.^ked to make all schools "more responsive
to our social, economic, and professional needs." The black
population's role in society was clear. The board beUeved "the
Negro must be educated and trained . . . that he may be more
sober, more industrious, more competent." When the GEB
finally came to support full-fledged colleges for blacks, it was not
because their general outlook on race relations had changed.
College training would be "provided for carefully selected
Negroes" who will "lead the race in its efforts to educate and
improve itself." The black's leaders "must be trained, so that,
looking to them for guidance as he does, he may be as well guided
as possible."''^

The GEB was not concerned only with education of blacks. It
worked to build up high schools for whites and for blacks
throughout the South. Always with an eye to creating "local
responsibility for self-help" — what Gates called the "foundation
of character and social life itself" — the board's strategy was to
stimulate and organize community support for school taxes. The
GEB got each state university to create a professorship for
secondary education. Then with the university's approval, the
board defined the duties of the position and named the person to
be hired and, in return, paid the person's salary and all his
expenses. The main function of this professor was not to teach
but to organize. He would visit the towns of his state — "as an
officer of the university, laden with its wisdom and its moral
authority" — and develop and channel local support for high
schools and taxes to support them. At the end of two decades of
work, the GEB had spent a little over $3 million promoting public
schools in the rural and urban South. They considered the plan
effective "beyond our most sanguine anticipations" and took
considerable credit for the 2,000 new high schools built in that
period at a cost of $60 million, for which annual appropriations in
the Southern states increased from $1.7 million in 1905 to $15
million in 1922 — "all raised by local taxation."^''

48 I ''Wholesale Philanthropy'

The public schools program of the GEB led to a farm
demonstration program run for the board by Seaman Knapp and
then to the first of a long tradition of public health programs
conducted by the Rockefeller foundations. Rooted in the same
concern for Southern economic and social development that
guided the public schools program, the public health programs, at
first in the Southern states and then exported around the world,
became important supports for the growing domination by U.S.
capital, trade, and military power. ''^ Gates, a charter member of
the GEB and its chairman from 1907 to 1917, was the eloquent
orator and, in Junior's words, "the brilliant dreamer and creator"
of most of these programs.

The permanence of the General Education Board was assured
with a broad congressional charter, dedicating the new founda-
tion to "the promotion of education within the United States."
Senator Nelson Aldrich, Junior's father-in-law and a powerful
representative of business in Washington, "took the bill into his
own hands and put it through in record time." It was officially
chartered in January 1903, a year after it began its first Southern
program, yet the most influential work of the GEB was yet to
come.^^

Gates took into his own bosom the worries about Rockefel-
ler's still-growing fortune. "I have lived with this great fortune of
yours daily for fifteen years," he wrote his employer in 1905. "To
it, its increase and its uses, I have given every thought, until it has
become a part of myself, almost as if it were my own."*°

Recognizing the mortahty that all persons must face, Gates
laid out the alternatives to Rockefeller. "One is that you and your
children, while living, shall make final and complete disposition
of this great trust, for the good of mankind. The other is that you
shall not do this, but shall hand it down to unborn generations,
for them to decide how this trust shall finally be discharged for
humanity."

For Gates, embracing Carnegie's "Gospel" and fearing the
"powerful tendencies to social demoralization" of inherited
wealth, the first alternative was the only moral one. He proposed
that Rockefeller decide what major lines of work for "human
progress" he wanted to serve and who should administer the
funds and then create an endowment "to provide funds in
perpetuity, under competent management, with proper provision
for succession."

"Wholesale Philanthropy" I 49

Gates then suggested several funds for different areas of
work — ''a great fund for the promotion of a system of higher
education in the United States, ... a fund for the promotion of
medical research throughout the world, ... a fund for the
promotion of the fine arts," and more. 'These funds should be so
large that to become a trustee of one of them is to make a man at
once a public character." The work of these enterprises should
employ "the best talent of the entire human race."

Junior followed this letter with his own enthusiastic endorse-
ment of Gates' proposal. Within two weeks Rockefeller, Sr.,
gave the General Education Board $10 million and followed that
a year and a half later with another $32 million. By 1921
Rockefeller's gifts to the GEB totaled more than $129 million.
Larger and more numerous endowments began to flow to the
Rockefeller Institute for Medical Research, fathered by Gates
from his employer's fortune in 1901, and soon discussions began
that led from Gates' 1905 letter to the creation of a much larger
and broader fund, the Rockefeller Foundation, to which Senior
gave more than $182 million.

It is not so clear that Gates' only concern in recommending
that Rockefeller himself dispose of his fortune was the danger of
inherited wealth to its possessors. The notoriety that accrued to
Rockefeller and other robber barons along with their profits cast
a long shadow on the future of wealth, and the Rockefellers felt
the chill as much as anyone. Henry Demarest Lloyd, in Wealth
Against Commonwealth published in 1894, and Ida Tarbell, in a
magazine series ending in 1904, had tarred and feathered the
Standard Oil Trust. The SociaHst movement was winning the
support of working people throughout the country for its program
to do away with private capital altogether. And perhaps most
frightening of all, upstanding middle-class Americans, profes-
sionals and businessmen with values very much like the Rockefel-
lers themselves, were joining the call for Progressive reforms.
The Progressive movement, while firmly supporting capitalism,
was calling for constraints on the accumulation and concentration
of private wealth. Roosevelt was elected in 1904 on a platform
that at least threatened to break up monopolies.

"I trembled," Gates later recalled, "as I witnessed the
unreasoning popular resentment at Mr. Rockefeller's riches, to
the mass of the people a national menace." Gates might believe
that Rockefeller "used his wealth always and only in the public

50 I "Wholesale Philanthropy"

interest," that his fortune had been created by economies rather
than by theft, that his wide investments in industry and finance
constituted "vast permanent contributions to the wealth and
well-being of the American people." But few people in the
country not connected with 26 Broadway agreed with him.^^

In the fall of 1906 the federal government launched a major
suit to break up the Standard Oil Trust, and that litigation began
its five-year journey through the courts. After Rockefeller gave
the GEB $32 million in 1907 to finance Gates' plan to create "a
system of higher education in the United States," many respect-
able newspapers and magazines suggested that "the purpose of
Mr. Rockefeller's large gift is to head off, if possible, the teaching
of socialism, which is on the increase ... in a number of
universities." Also in 1907 federal Judge Kenesaw Mountain
Landis hit the Indiana Standard company with a $29 million fine
for obtaining rebates on its railroad shipments, one of the
"economies" in which Gates and Rockefeller took pride. "No
oriental despot . . . has committed such arbitrary acts of confis-
cation as the present administration is responsible for under the
forms of law," Gates railed. ^^

The Landis fine was quashed on appeal, but the spectre of
dissolution and ultimately of confiscation pursued the Rockefel-
lers and many of their class. The Rockefeller philanthropies
created new programs and with them new images for the
benefactors. The programs appealed to their perceptions of social
needs, but in their perceptions, society's needs were indistin-
guishable from their own. Colleges were expanded and organized
into a system of higher education to produce the professionals
and managers the corporate society badly needed, but the GEB
for two decades consciously followed Gates' directive to strength-
en private rather than state universities because private institu-
tions, controlled by men and women like themselves, would be
more likely to "direct popular opinion into right channels."*^ The
medical philanthropies, outwardly appearing only to fill an
obvious social need, helped to develop a medical care system
peculiarly suited to the needs of corporate capitahsm, as we will
see in subsequent chapters.

SOCIAL MANAGERS FOR A CORPORATE SOCIETY

It is clear that John D. Rockefeller, Sr., was neither the
initiator nor the strategist in his philanthropies. In the early years

''Wholesale Philanthropy" I 51

it was Gates and then Gates and Junior whose ideas and
strategies shaped the elder Rockefeller's fortune into purposeful
programs. In part the insight they showed concerning the needs
of capitalist society may be attributed to their individual personal-
ities, shaped by their own Ufe experiences. But they were also
representative of the new class of men (and very few women at
that time) who provided the managerial skills needed by corpo-
rate industry and finance. Unhke the individualistic entrepre-
neurs who built the enormous industrial and financial empires
around themselves in the latter nineteenth century, these new
managers were more sensitive to the smooth workings of their
enterprises.

In industry, management's role was to rationalize production,
to divide the productive process into "efficient" units, and
simultaneously to coordinate each with the other to produce a
unified organization, hnked in a similarly coordinated fashion
with disparate sources of investment capital and raw materials at
one end of the production line and with a system of distribution
and marketing at the other end. Analogous managerial roles were
also developed in government bureaus and departments, then in
colleges and the emerging universities. The last major area to
which skilled management was directed were the social ser-
vices— charity and social welfare programs, philanthropic founda-
tions, and medicine.

The foundations were key instruments in early efforts to
rationalize social services, public health, and medical care under
the control of specially trained managers in those fields, and the
foundations themselves became the turf of this same management
class. It made little difference whether one owned a substantial
share of the country's corporate wealth or whether one simply ran
the factories and institutions owned by the wealthy. The actions
of each group were essentially the same, and their values were
quite similar. They both accepted the prevaihng economic, social,
and political system as given, and they sought to make the system
work smoothly.

Some of these system managers used charity to try to make
capitalist society, whose ideal model is a purely competitive
marketplace, a less "rigid and heartless" one, as a recent
proponent of this view put it. He believes that philanthropy
should "provide at least some softening of the corners and
relaxation of the rigid rule of self-interest. "*"*

52 I ''Wholesale Philanthropy"

Others like Gates and John D. Rockefeller, Jr., conceived of
a more strategic role for philanthropy — the transformation of
social institutions. They worked to make the nation's colleges and
universities into a system that would more efficiently yield
technically trained and properly socialized professionals and
managers for the system. They developed new roles for profes-
sionals as managers, and they helped rationalize the institutions
in which these professionals worked.

Men like the Senior Rockefeller and Andrew Carnegie knew
little of this work. They had understood its relevance to industry
where they had been the first ones in oil and steel, respectively, to
create vertically integrated corporations, owning or controlling
the entire process from oil wells and iron ore mines, to transpor-
tation, refining and manufacturing, distribution, and marketing.
But running a corporation is different from running a corporate
society, and though they understood the need to take more
control over social institutions, they did not understand how.

Carnegie, egotistical and individualistic, thought he under-
stood. Until Andrew Carnegie began giving away libraries in the
1880s, the world had never seen such a vast fortune apphed to
private philanthropy. This remarkable innovation in magnitude
of philanthropic wealth — due, of course, to his insatiable ambi-
tion in industry rather than to any strategic genius in philan-
thropy— gave him a social power so vast that it proved truly befud-
dhng. Armed with a crude social philosophy, he set forth to civilize
the lower classes and set a model of responsibility for the upper
echelons of society. The society he hoped to preserve was one
based expHcitly on enormous disparities of wealth. And he
attempted to preserve the individualism he and other Social
Darwinists revered with a largely individualistic approach to
social transformation. His programs represented his own person-
alized views, shared in varying degrees by contemporary capital-
ists. But Carnegie's vision was a limited one and his programs
often stepped over the edge into absurdity. When Carnegie
retired from the steel business in 1901, his philanthropic plans
were vague and scattered. In the words of his biographer Joseph
F. Wall, "For someone who had written so extensively and
preached so eloquently as he on the duties of the man of wealth,
it is rather surprising that he faced this task better armed with
platitudes than with any concrete program of action."^

'85

"Wholesale Philanthropy" I 53

After several years of massive spending without a real plan,
Carnegie set up his foundations, and his hired managers began
accomplishing what he had not. In 1905 Carnegie began to move
from his individualistic method of dispersing money to a more
rationalized, systematic model. Appalled by the pitiful incomes
of college professors — usually not more than $400 per year —
Carnegie had meant to do something about them for some time.
But it was Henry S. Pritchett, the president of the Massachusetts
Institute of Technology, who moved him to action. While visiting
Carnegie at his ancient castle in the Scottish Highlands in the
summer of 1904, Pritchett lamented the difficulties he had in
attracting young scientists and engineers to teach at MIT.
Academic salaries could not compare with those offered by
private industry, and few colleges even had pension systems to
provide a minimum of financial security for professors. There
were more discussions the following winter, and in April 1905
Carnegie announced the creation of his college teachers pension
fund with an initial endowment of $10 miUion in U.S. Steel
bonds. A board of trustees was selected consisting mainly of the
presidents of the most elite universities and colleges in the
country. Pritchett was appointed president of the new Carnegie
Foundation for the Advancement of Teaching.*^

Under Pritchett's guidance the new foundation set out to
recast American higher education. The free pensions became the
carrot-at-the-end-of-the-stick that colleges would follow down
the path of reform. An applicant college or university had to have
a minimum of $200,000 endowment to qualify for the pension
program. Neither state colleges nor those controlled by rehgious
denominations were eligible. Finally, to be eligible a school had
to require of its students a prescribed minimum of high school
preparation prior to admission. This last requirement proved a
successful attempt by the foundation to "throw its influence" in
favor of a "differentiation between the secondary school and the
college" in order to create "a system of schools intelligently
related to each other and to the ambitions and needs of a
democracy." Although only fifty-two of the original 421 appli-
cants were eligible for the pension plan, other schools soon
modeled themselves on the Carnegie system to make themselves
eligible. Denominational colleges cut loose from their controlling
churches to take advantage of the plan, and the foundation's rules

54 I "Wholesale Philanthropy"

were changed to include state institutions. Soon virtually every
high school and college in the country measured student progress
in "Carnegie units." A national system of education was taking
shape with the prodding of Carnegie pensions and the Carnegie
Foundation as the unofficial accrediting body.^''

Almost immediately after opening the offices of the Carnegie
Foundation, Pritchett began consulting with the General Educa-
tion Board. His only regret, he told GEB executive secretary
Wallace Buttrick, was that "I did not come to you before renting
my office for it would be of great benefit to us to be located near
you." Pritchett admired Gates, often asked for his advice, and
tried to get Carnegie to mend his philanthropic ways. In fact the
record left behind suggests that Pritchett's ideas on systematizing
higher education were derived from Gates.**

The leadership that attracted this following was Gates' vision
of how wealth could rationalize higher education. He described a
picture of the GEB, through its "moral influence" as well as its
money, fostering cooperation among colleges and universities
and securing economies "in administration, in teaching force and
in the use of men." He hoped that such a philanthropic board,
properly endowed, would "select" and "direct" the resources of
higher education, much as the Standard Oil Company had
transformed the "universal competitive system" that character-
ized the oil industry in 1870.*^

Rockefeller was fortunate to find a man like Gates to develop
"wholesale philanthropy" for him. As Junior and other officers of
the Rockefeller foundations readily admitted, Gates was the
source of most strategic ideas, major programs, and important
policies in the foundations' first decade and a half, with Junior
developing an increasingly important role. In that time there was
no serious challenge raised to Gates' dominance. The board of
trustees was the final authority, but other staff members knew
that if they had Gates' or Junior's support, "we were on safe
ground" and would have little problem winning approval from
the board. '«

Gradually, however. Gates' influence declined. While the
times changed and the much younger Junior became a leader of
the growing image of corporate responsibility and concern.
Gates' limitations became apparent. Following the 1914 massacre
of striking miners and their wives and children in a Ludlow,

"Wholesale Philanthropy" I 55

Colorado, mining company controlled by the Rockefellers,
Junior was held largely responsible by public opinion throughout
the nation. But the posture he developed afterward, formulated
by consultant W. L. Mackenzie King, made him the leading
representative of the new, more benign face of industrial re-
lations that was winning support from many corporate execu-
tives. When Junior, who had been called before a Presidential
commission created to investigate such problems, claimed he
thought it perfectly proper for "labor to associate itself into
organized groups for the advancement of its legitimate interests,"
Gates criticized him for adopting a "spirit of conciliation toward
those who came to him in the spirit of these Unionists." Yet it
was Junior's support of company unions that was assuaging public
opinion and winning the respect of other corporate leaders. Gates
did not adapt himself to the changing times. ^'

With Gates' leadership passing from the scene, especially
following his resignation from the GEB executive committee in
1917, problems of accountability began to be raised. Trustees
who had willingly followed Gates now found the foundations
without comparable leadership. Other foundation officers had
never demonstrated the broad and clear perspective that Gates
had shown, and with Gates gone from daily participation in
foundation activities, a vacuum was created. Trustees wanted to
fill it by increasing their participation. Foundation officers
quarreled with one another. The foundations drifted. ^^

With Gates these problems did not arise because his carefully
developed and forcefully presented proposals won immediate
support. Gates never expected the trustees to play an important
role in social innovation. When a trustee suggested that GEB
members were appointed to throw new light on "the great
problem of education in this country," Gates impatiently ex-
plained that he and Rockefeller gave an "overwhelming prepon-
derance to business men" in composing the board "to fix the
policies of this Board along the lines of successful experience."
They knew, he said, that "successful business men would steer
the ship along traditional Hnes and would not be carried out of
their course by any temporary breeze or even by hurricanes of
sentiment. "^^ The trustees were there to assure in perpetuity that
Rockefeller's money would be judiciously applied to preserving
the system and strengthening it, letting professional educators

56 I ''Wholesale Philanthropy

promote innovative ideas while the trustees supported only those
directions which seemed desirable and whose consequences were
more certain.

Though Gates ran the GEB with firm leadership and a fiery
tongue during his tenure as chairman, he and Junior both wanted
the other trustees to take an active interest in the foundation.
Without involvement, their interest and sense of responsibility
for the fortune would decrease — the very thing to be avoided. "In
the remote future," Junior advised his father, "you must of
necessity trust to the character and integrity of the men who come
after you."^"^

It was clearly just as important to encourage local communi-
ties to take "responsibility for self-help." Gates' reasons for this
guiding principle were moral, tactical, and strategic. He believed
in the moral precepts of self-reliance and self-discipline. He also
wanted to enlist the active participation of property owners in
community institutions. Although they were not as reliable as the
men appointed to the Rockefeller foundations, the local ruHng
classes recognized, as did he, that "the right to earn and hold
surplus wealth marks the dawn of civilization."^^ Gates, Junior,
and Rockefeller all understood that to fund a local institution
without requiring contributions and participation from local men
and women of wealth would be to lessen these people's sense of
responsibility for what goes on in the institution. They had a
genuine concern for the preservation of their society, and its
preservation required the active involvement of all those who had
a stake in it.

Rockefeller's involvement with the University of Chicago is a
good example of this principle in action. Rockefeller contributed
$35 million to the university during its first two decades compared
with $7 million from all other donors. He was consulted about
appointments to the board of trustees and approved the initial Hst
before it was finalized. But thereafter Rockefeller did not desire
to control the university, as many people charged. "He prefers to
rest the whole weight of the management on the shoulders of the
proper officers," Gates wrote the university president on behalf
of his boss in 1892. "Donors can be certain that their gifts will be
preserved and made continuously and largely useful, after their
own voices can no longer be heard, only in so far as they see
wisdom and skill in the management, quite independently of

''Wholesale Philanthropy" I 57

themselves, now." Rockefeller's trust in the management was
well founded. There is no evidence that he ever tried directly to
influence the university administration to fire teachers who
expressed radical views. It was University of Chicago president
Harper who took the initiative to drop Professor Edward Bemis
after he made a speech, following the 1894 Pullman strike, critical
of the railroads. Rockefeller and Gates had merely appointed the
"right" men to manage their philanthropic and financial enter-
prises, men who were led by values and considerations similar to
their own and who could be counted on to do what was expected.
In many ways, local authorities in whom Rockefeller placed his
trust proved the correctness of this rule.^^

One final and important tactical reason for securing local
involvement was to multiply the impact of each grant. The
Rockefeller foundations required virtually all recipients to raise
an amount equal to, or as much as four times greater than, the
grant being given by the foundation. Besides being chosen for
their stabilizing influence, foundation trustees were also chosen
for "the prestige and authority of their names." Andrew Carne-
gie, Long Island Railroad president Wilham H. Baldwin, Har-
vard president Charles W. Eliot, Johns Hopkins president Daniel
Coit Oilman, pubhsher Walter Hines Page, banker Oeorge
Foster Peabody, and other prestigious individuals were appointed
to the OEB to "secure general public approval and active and
powerful pubhc cooperation" for OEB programs. In gaining
public support and in requiring matching contributions from
others, the foundation was able to multiply the impact of the
grant programs. By 1925 the OEB had given $60 million to the
endowments of colleges and universities in the United States for
certain reforms they deemed desirable, and they had, by their
matching-grant policy, required the institutions to raise an addi-
tional $140 million to support these OEB-required changes. By
1928 the Oeneral Education Board had contributed some $50 mil-
lion to medical schools for very specific reforms,* generating
total resources estimated at ten times that amount for those
same reforms.^^

Thus the Rockefeller philanthropies, under the guidance of
skilled managers, developed self-consciously strategic programs

*This program is described in detail in Chapter 4.

58 I "Wholesale Philanthropy"

to transform higher education and medical care, among other
social institutions. The thrust of their programs was to systema-
tize and rationalize these institutions to make them better serve
the needs of corporate capitalism.

The rise of industrial capitalism brought with it many new
needs that provided opportunities for groups besides the capital-
ist class. The work process was reshaped to reduce the costs and
increase management's control of production. Scientists devel-
oped the basic understandings on which technological innovation
was based. Engineers adapted scientific knowledge to produc-
tion, designing new methods and machines that reduced the need
for skilled workers, increased productivity, and generally gave
management more complete control of the entire production
process.

A new stratum of managers and professionals emerged in the
society's class structure to design and organize production and the
institutions that reproduce and control capitalist society's social
relations. Colleges and universities became the training and
research agencies, producing knowledge and reproducing engi-
neers, scientists, lawyers, teachers, and other technicians and
social managers. Managers were well paid for their efforts, and
some, like Gates, were incorporated into the highest circles of the
owning class. But despite their separation from predominant
ownership, managers of corporations and institutions alike "still
think and act as though the firm belonged to them," as William
Appleman WiUiams put it.^* Their commitments to the prevailing
economic system are complete.

Out of an earlier mercantilist philanthropy grew a new
corporate philanthropy, intended not to ameliorate the lot of
industrial capitalism's victims but to shape and guide social
institutions. Foundations were, and still are, important ramparts
through which private wealth, acting through creative and loyal
managers, influences and often controls universities, medical
schools, and other "public" institutions. The Rockefeller foun-
dations established directions and strategies that other foun-
dations followed. Gates led the Rockefeller philanthropies with
his "imagination, daring, and an intuitive sense of educational
strategy. "^^ Pritchett, following Gates' leadership, made Carne-
gie's foundation an engine of social transformation. In many

''Wholesale Philanthropy" I 59

ways, Gates, Pritchett, and other managers understood the
workings and needs of capitaHsm better than the ostensible
owners of the system did.

Broad social transformations, however, require the participa-
tion of more than the ruling class. While the working class
suffered greatly from the capitalist reorganization of production,
some groups attached themselves to the ascending corporate class
and benefited greatly. New occupations, like engineering and
social work, and old ones, like law and medicine, gained elevated
professional status in return for becoming the new order's
managers of production or social relations. Medicine's almost
fantastic transformation from rank ignominy to Olympian heights
of status exemplifies the powerful consequences of an interest
group adapting itself to the needs of the dominant class.

CHAPTER

Scientific Medicine I:
Ideology of

Professional Uplift

Throughout the nineteenth century the medical profession was
almost constantly frustrated in its attempts to gain public con-
fidence and raise professional incomes and status. Despite varied
attempts to alter the competitive market economy for medical
services, the dominant portion of the profession continued to
be plagued by competition within its own ranks and from those
beyond the pale of orthodoxy.

In this chapter we will see how the rise of science in the latter
part of the century provided the solution that medical reformers
had previously sought in vain. Physicians and biological research-
ers consciously applied the methods and principles of scientific
research to problems of disease, though even in the 1860s their
work had Httle support and played a very minor role within the
medical profession. At about midcentury, however, leading
reformers among elite medical practitioners took up "scientific
medicine" as the ideology of professional reform and uplift.
Medical science gradually provided practitioners with a some-
what more effective medical practice, enabling them to increase
their credibility with the public and reduce economic competition
within the profession. "Scientific medicine" was adopted as the
unifying theory that enabled the dominant profession to develop
strong political organization and to win political and financial

Scientific Medicine I I 61

support from wealthy people in society. Perhaps most fundamen-
tal, the association of medicine with science won support from the
new technical, professional, and managerial groups associated
with the growth of corporate capitalism.

AMERICAN MEDICINE IN THE 1800s

In 1800, nearly all American physicians received their training
as apprentices at the side of a practicing physician, assisting with
simple techniques and mixing medications. In the eighteenth
century, medical lectures had not been widely available in this
country, so young men from the upper class went abroad for their
medical education, especially to Scotland. The handful of
Edinburgh-trained physicians in America developed very success-
ful practices, with the wealthiest citydwellers for their clients and
lucrative consulting practices besides. By 1800 only about a
hundred American physicians had attended medical courses at
Edinburgh, and only three American medical programs — at
Pennsylvania, Harvard, and Dartmouth — were offering lectures
to supplement the apprenticeship. The graduates of these institu-
tions formed a medical elite, and together with the rank-and-file
apprentice-trained physicians they formed the self-styled "regu-
lar" profession.^

But most Americans were probably not getting their medical
care from "regular" physicians. Whereas most of the populace
lived in the countryside or small towns, most apprentice-trained
doctors and the few medical school graduates lived in the large
towns and cities. In Virginia, by 1800 the eleven largest towns had
only 3 percent of the state's population, yet 25 percent of all
physicians known to have practiced in Virginia during the
eighteenth century lived in those eleven towns. ^

Most Americans, when they were sick, consulted herbal
practitioners. These empirical healers had no formal training but
apprenticed mainly with other herbalists. Some of the herbalists
were midwives, and others were men and women who had
experimented with herbs and were known for their abilities to
heal the sick. Lay healers were distributed throughout the
countryside. They seldom rehed on healing for their entire
support and charged little for their services.^ Regular physicians
were increasingly plying their art on a full-time basis and charging

62 I Scientific Medicine I

substantially higher fees, often supported by medical societies'
pubhshing "fee bills" to place a floor under competing doctors'
charges.

The maldistribution of regular physicians and their higher fees
were only two reasons why the regular profession was widely
unpopular in the first half of the nineteenth century. Very much
related to their social, economic, and geographic separation from
the populace, the orthodox profession's clinical practice was
greatly feared by much of the population. Not only did medicine
offer little hope for curing disease, but the heroic methods used
by regular doctors were unpleasant and often lethal. The lancet
was the physician's indispensable tool for nearly every ailment.
Benjamin Rush, the most prominent physician in America from
the Revolution through Jefferson's time, urged bleeding for
yellow fever "not only in cases where the pulse was full and
quick, but where it was slow and tense.'"* When bleeding was not
recommended, and even when it was, calomel (chloride of
mercury), jalap, or another purgative was administered. The
violent vomiting and purging that resulted were more detested
than even the pus-filled blisters induced as another form of
therapy. After attacking the body as well as the disease with
bleeding, blistering, and purging, the physician administered an
arsenic tonic to restore the weakened patient's vigor.

Against this distasteful and frequently disastrous treatment by
regular physicians, the empirical herbaHsts' mild treatments were
pleasanter and at the very least did not interfere with natural
rates of recovery. Their mild emetics and stimulants seemed
closer to nature than the regulars' profuse blood-letting and harsh
purges.^

Still experiencing competition from the empirically grounded
herbalists, regular physicians resorted to ever larger doses of their
therapies through the first half of the nineteenth century.
BeUeving that any desired change in a patient's gross symptoms
was to the good and seeking to distinguish their art from lay
practice, regular doctors bled their patients more profusely and
doubled and tripled their doses of calomel and jalap. The
profession's heroic therapy became the focus of increasingly
bitter and widespread attacks. Thomas Jefferson called them an
"inexperienced and presumptuous band of medical tyros let loose
upon the world." By the middle of the century cholera victims
were given an even chance of being done in by the disease or by

Scientific Medicine I I 63

the doctor. The profession's fearsome and futile methods reduced
pubHc confidence in regular doctors to an all-time low.^

Leading local and regional members of the profession tried
many methods of increasing public confidence in doctors and
reducing competition. At various times during the nineteenth
century, they sought licensing laws, formed new medical sects,
started medical schools and issued diplomas, organized state and
national medical societies, demanded medical school reforms,
and adopted codes of ethics, all with little or no improvement in
technical effectiveness, credibility with the public, or their own
status and fortunes.

LICENSING

Despite the antipathy of much of the populace, regular
doctors at the end of the eighteenth century persuaded fellow
gentlemen in the state legislatures to pass medical licensing laws
to restrict or prohibit practice by herbal healers. Licensure
bestowed exclusively on regular physicians the right to sue for
fees. The legally sanctioned economic privilege did not provide
the regular profession with an economic monopoly, but it did set
them apart from and above lay healers and most other Ameri-
cans.

In addition to the public's lack of confidence in regular
physicians' clinical methods, populists in the Jacksonian era
articulated their opposition to any form of class privilege. By 1850
medical licensing laws were repealed in nearly every state
through the efforts of the Popular Health Movement, a loose
populist movement of lay healers, herbal practitioners, artisans,
farmers, and working people who fought to remove the legal
sanctions that protected the privileged position of physicians.''

MEDICAL SECTS AND MEDICAL SCHOOLS

The humiliated profession was badly divided. Many physi-
cians, critical of heroic medicine, were attracted to the pleasanter
new professional sects, such as homeopathy and eclecticism, that
were growing in popularity. These sects built their materia
medica around herbal drugs or some distinctive technology or
procedure, each adding elements that enabled them to claim the
necessity of extended study in their field.

64 I Scientific Medicine I

Homeopathy, as formulated by its founder Samuel Hahne-
mann (a German physician), was based on the widely accepted
medical view that the symptoms of a disease constitute the
disease itself and, a corollary, that eliminating the symptoms
constitutes a cure. Hahnemann found that some drugs produced
the same symptoms in a healthy person (that is, caused the
"illness") that they eliminated in a sick person (whom they
"cured"). For example, he found that cinchona bark, at the time
used to relieve the symptoms of malaria, produced malarial
symptoms in a healthy person. From these observations he
developed what he called the law of similia similibus curantur — or
"like cures like." Hahnemann also maintained that diluting the
dosage of a drug down to one ten-thousandth or one-millionth of
its original strength increased the drug's potency.*

Competition between the sects and the lack of decisive public
support for any one of them, left none of the sects in a position to
establish control through licensing. The orthodox profession and
the other sects turned to medical education and degrees as a
method of recruiting and certifying new physicians in their ranks
and uplifting the profession. Medical schools proliferated
throughout the country, and some 400 were founded between
1800 and 1900.^ Local physicians organized schools to supplement
their practices with lecture fees paid by medical students and,
through their graduates, to fatten their incomes with increased
consultations. At a time when physicians considered $1,000 to
$2,000 a year a good income, the average part-time medical
school faculty member earned more than $5,000 annually from
student fees and private practice while more enterprising and
popular colleagues earned at least $10,000.^° Like hundreds of
general colleges started before the Civil War by rival Protestant
sects and political groups, many medical schools were started by
rival medical sects to improve their competitive position vis-a-vis
other sects. The orthodox profession controlled by far the largest
number of schools. ^^

The proliferation of medical schools in the 1800s assured the
dominance of diploma-carrying regular doctors over lay healers
and physicians of other sects. By 1860 regular physicians outnum-
bered other sectarian doctors ten to one.^^ The inexpensive and
widely dispersed medical colleges encouraged large numbers of
young men and some women to attempt careers in medicine.

Scientific Medicine I I 65

Graduates, many of them from yeoman farming and working-
class families, filled the cities, towns, and countryside of Ameri-
ca. Elite* regular physicians resented the competition within the
dominant sect, but they saved their most venomous denuncia-
tions for competing sects. The sectarian doctor was "the greatest
foe to the medical profession," argued the dean of the Tulane
University medical department, because he was "an obstacle to
the financial success of the respectable medical practitioner."'^

As the number of physicians increased, organized doctors
became increasingly worried. It was clear to all physicians that
producing a lot of doctors would lower rather than raise the status
and incomes of the profession as a whole. Lacking the public
support necessary for effective medical licensing laws and still
smarting from the humiliating defeat of medical licensing earlier
in the century, the reformers turned to medical school reform.
Raising medical school standards and thereby reducing their
enrollment, medical reformers believed, would simultaneously
win public confidence in medical practice and reduce the output
of doctors. The problem they faced was how to control the
independent, proprietary medical schools.

MEDICAL SOCIETIES

Local and state medical societies, representing the practition-
ers, fought with medical schools in their areas. In 1847 the
societies banded together to form the American Medical Associa-
tion (AM A). At the founding convention, leading practitioners
passed resolutions that sought to raise requirements for prelimi-
nary education prior to admission to medical school. So few
Americans had the requisite education at the time that enforce-
ment of these standards, according to historian William Roth-
stein, "would have closed down practically every medical school
in the country, and would have depleted the ranks of formally
educated physicians in a few years. "'"*

From its founding onward, the AMA was hostile to the
interests of proprietary medical colleges and their faculties. The
practitioners wanted to reduce the output of medical schools in

*The term "elite" refers somewhat loosely to physicians who, by their reputations for
clinical or research techniques, by income, and/or by organizational leadership positions,
had achieved prominence within the profession.

66 I Scientific Medicine I

order to reduce competition within the profession, while the
medical faculties opposed any attempted reforms because of their
interests in maximizing their lecture fees and future consulting
fees. Unfortunately for the practitioners, the reform leadership
mistakenly thought that including medical schools in the new
national organization would allow the medical societies to control
them. This strategic mistake immobilized the AMA as the
vanguard of practitioners' interests until 1874 when medical
college voting rights in the association were abolished.

CODES OF ETHICS

The AMA's attacks on medical education and especially on
other medical sects were supported by a "code of ethics" adopted
at their first convention. With the code the AMA hoped to deny
the ability of patients to judge their physicians or disagreements
between physicians, to encourage attacks on "irregular" doctors
and "quacks," and generally to reduce competition among
regular physicians. At the same time that the AMA complained
about the low standards of medical education, the association
commanded patients to trust their doctors. "The obedience of a
patient to the prescriptions of his doctor should be prompt and
impHcit," the code of ethics instructed. The patient "should never
permit his own crude opinions as to their fitness to influence his
attention to them."^^

These efforts to bolster the profession's falling economic
status and power were legitimized on moral and ethical grounds
by the medical societies. Since the colonial period, violation of
"ethical codes" had been grounds for ostracizing nonconforming
physicians. Codes were used not only against other sects and lay
healers but against members of the regular profession who
consulted with homeopaths and eclectics and even against the
developing medical specialties which offered competition to the
general practitioners. The AMA code failed to win public support
or stamp out competition although the medical societies' attacks
on members for code violations intimidated some doctors and
increased intraprofessional antagonisms.'^

In short, conflicts between practitioners and medical faculties,
generalists and specialists, and "regular" physicians and other
sects kept the profession badly divided throughout the nineteenth
century. The incoherent strategy of the regular profession's

Scientific Medicine I I 67

leadership and the weak structure of their organization, the
AM A, left the field with no sect able to secure undisputed control
over the competitive marketplace.

Medical school output continued unabated. By the end of the
nineteenth century, the United States averaged one physician to
every 568 people. ^^ Compared with prevailing ratios in European
countries (Germany, with one doctor to 2,000 population, was
the favorite example), the United States was "overcrowded" with
physicians. Physicians' incomes ran the gamut from poor ($200 a
year) to wealthy (as much as $30,000 a year for a small number of
elite doctors). The chief complaints of the most prominent
professional spokesmen by the end of the century were the
"surplus" of doctors, "low" incomes, and the low social status of
the profession.

Three underlying problems plagued medical reformers who
tried to heal these wounds. First, physicians lacked an agreed
upon technical basis for settling among themselves disputes
between the sects. Without public consensus on technical criteria
of effectiveness and validity, all sects competed for business in the
medical market. But without sufficient public confidence in the
validity of any one sect, no sect could win a monopoly of medical
practice and thereby eliminate the competition.

Second, their lack of a technical basis for establishing public
support put them all in a weak position to establish political
control over entry into medical practice. Earlier efforts to use
licensing ended in humiliating defeat for the regular profession
because of organized opposition from other sects and a distrustful
public.

Third, within at least the dominant sect different economic
interests divided those who practiced medicine from those who
trained future practitioners. Practitioners wanted to restrict the
supply of physicians, and part-time faculty wanted to preserve
institutions that were lucrative additions to their own practices.

INCOMPLETE PROFESSIONALIZATION

Without actually having public confidence in their technical
ability, physicians throughout the nineteenth century and earlier
had nevertheless proclaimed norms to support their authority
over the lay public. Demands for recognition of the regular
profession's technical competence (in which they undoubtedly

68 I Scientific Medicine I

believed) were the means of legitimating their claims to profes-
sional authority. The recognition of that authority, however, was
seen as necessary to the profession's controlling the economic
conditions of its work. By proclaiming a set of norms and values
associated with their work, regular physicians hoped to end the
competitive market for medical services and to win a regulated
market for themselves.

The basis of professional status and power is still debated by
sociologists, who traditionally have posed a set of essential
features that are supposed to distinguish professions from the
general run of occupations. In 1928, A. M. Carr-Saunders, the
father of the sociology of professions, defined a profession as an
occupation: (1) based on specialized intellectual training or study,
(2) providing a skilled service to others, and (3) in return for a fee
or salary. ^^ Thirty years later, William Goode stressed prolonged
specialized training in a body of abstract knowledge and a
collectivity or service orientation as the "core characteristics" of
professions.^^ The list of formal characteristics of professions has
been extended by other sociologists to include a systematic body
of theory, acceptance of the authority of the professional by all
who come to him or her as clients, protection of the professional's
authority by the political community, a code of ethics to regulate
professional relations, and a set of values, norms and symbols
that build solidarity among the profession's members. ^°

However, lists of formal characteristics turn out to be fairly
useless in the real world in distinguishing professions from other
occupations. Even worse, they tend to gloss over the political and
economic dynamics that are essential to the process of profes-
sionalization, making professional status and power appear an
inevitable and desirable feature of modern societies. In reality, as
Eliot Freidson has observed, any occupation wishing professional
status creates a systematic body of theory, claims exclusive
authority of its practitioners, adopts a code of ethics, tries to build
solidarity among its practitioners around formal values, norms,
and symbols, and otherwise cloaks itself with the well-known
medallions of professions to support its claims. "If there is no
systematic body of theory," Freidson argues, "it is created for the
purpose of being able to say there is."^^

The commitment to service, argues Harold Wilensky, is "the
pivot around which the moral claim to professional status

Scientific Medicine I I 69

revolves."" Like many such professional norms, there remains
no clear evidence that a service orientation is in fact strong and
widespread among professionals. In reviewing the sociological
literature that makes such claims, Freidson has concluded: "the
blunt fact is that discussions of professions assume or assert by
definition and without supporting empirical evidence that 'service
orientation' is especially common among professionals."^^

Indeed, many academic social scientists have been beguiled
by their own (usually self-serving) beliefs in "science" and
"expertise" into confusing professional norms with the reality of
professional practice and motivation. Codes of ethics were
accepted by some sociologists as genuine efforts by the profession
to guarantee competence and honor. Carr-Saunders believed that
"if the foundations of the codes were better understood, they
would not be generally regarded with hostility. "^"^

More recently, some sociologists have approached profession-
al norms more critically. Everett Hughes, for example, argues
that the widespread acceptance of norms, hke the professional
"should have almost complete control over what he does for the
client" and "only the professional can say when his colleague
makes a mistake," have been used by professionals to hide
mistakes. ^^

What much of the sociological literature ignores in examining
the process of professionalization is how essential political power
is in gaining and maintaining professional status. As the history of
the medical profession in the nineteenth century demonstrates,
without sufficient political power the profession remained unable
to control its economic and working conditions. Initial efforts at
licensure were defeated by a popular movement of lay healers
and other Jacksonian-era populists. Attempts to use medical
education as a strategy of reform were thwarted by the organized
profession's lack of control over medical schools. The leading
reformers organized a national professional association, but the
medical school faculties were beyond the reach of the American
Medical Association. Ethical codes, articulating prevaihng pro-
fessional norms, failed to win public support for the profession
and could not overcome intraprofessional competition. What the
medical reformers sought was the power to enforce the instru-
ments of professionalism that assure high incomes, social status,
and continued prosperity for the profession.

70 I Scientific Medicine I

Freidson is adamant in this interpretation of professionaliza-
tion. "Not training as such, but only the issue of autonomy and
control over training granted the occupation by an elite or public
persuaded of its importance seems to be able to distinguish clearly
among occupations," he argues. "And the process determining
the outcome is essentially poHtical and social rather than techni-
cal in character — a process in which power and persuasive
rhetoric are of greater importance than the objective character of
knowledge, training, and work." The nature of training, as well
as the service ideal, ethical code, and body of abstract theory
constitute a profession's "ideology, a deliberate rhetoric in a
political process of lobbying, public relations, and other forms of
persuasion to attain a desirable end — full control over its
work."'^

The history of medicine, from this perspective, can be
understood as a political process in which the specific reforms —
however much they may increase the technical effectiveness of
physicians — are also instruments of persuasion and symbols of
legitimacy. The goals of reform leaders were to gain collective
control for the profession over its working conditions and
economics in order to establish a hierarchy of authority and
power among healing occupations, to assure that physicians reign
firmly at the top of the hierarchy, and to assure them as high
incomes as possible in any given historical period.

Support for such interests would have to come from outside
the profession. While efforts were made to win the credibility of
"the public," leaders of the profession did not see their struggle
as a grassroots campaign. Seeking a social and economic position
above the majority of the population, they could at best hope for
the acquiescence of the people. Active support would have to
come from the already higher social classes. In the eighteenth
century, practitioners had turned to gentlemen farmers and
wealthy merchants in the state legislatures to protect their in-
terests. In the nineteenth century a political rebellion from below
demonstrated the insufficiency of merely legislated sanctions.
Furthermore, political power increasingly rested in a new class in
society — those capitalists who controlled great manufacturing
and marketing enterprises. These were the men who, for good
or bad, were changing the face of the nation. Around their en-
terprises grew the great cities. From their factories came the

Scientific Medicine 1/71

steel and machines that enabled the same men to unify the
country commercially with railroads, products, and even armies.
From their corporations came the demand for foreign resources
and the products for foreign markets that were rapidly making
America a world power. This was the ascending class in America
at the end of the nineteenth century. Those groups in society who
connected with their enterprises or their interests could rise with
them.

It became clear to increasing numbers of physicians that the
complete professionalization of medicine could come only when
they developed an ideology and a practice that was consistent
with the ideas and interests of socially and politically dominant
groups in the society. It was desirable that everyone in society
recognize their technical effectiveness, but it was essential that the
classes and groups associated with the ascending social order
believe in their efficacy. The development and increasing domi-
nance of scientific medicine within the profession provided the
virtually perfect material and ideological basis for an alliance of
the medical profession with other professionals (mainly engineers
and lawyers), corporate managers, and all ranks of the capitalist
class. The medical profession discovered an ideology that was
compatible with the world view of, and politically and economi-
cally useful to, the capitalist class and the emerging managerial
and professional stratum.

MEDICINE AS SCIENCE

Medical research was flourishing in Germany and France
during the nineteenth century, and even in the United States
biologists and physicians made their contributions. In 1818
Valentine Mott, a New York physician, was among the first to
attempt major arterial surgery near the heart. Other Americans
also attempted new surgical procedures while some physicians
contributed new understandings to internal medicine. The New
York Academy of Medicine, founded in 1847, and the Pathologi-
cal Society in Philadelphia promoted discussion of medical
research and science.^''

Few of the findings and developments in medical research
were directly useful in improving medical practice. It is doubtful
that many patients survived the new surgical techniques in the

72 I Scientific Medicine I

absence of aseptic practices. While the differentiation of diseases
made observation more precise, the usual heroic treatments were
just as likely to do the patient in as before.

Beginning in midcentury, medical research in Europe started
producing more applicable findings. In 1858 Rudolf Virchow
unveiled a general concept of disease based on the cellular
structure of the body. From the findings of cell physiology,
anatomy, and pathology, Pasteur, Koch, and other medical
researchers developed new concepts and applications of bacteri-
ology.^^ In the last quarter of the century specialized German
laboratories began to replace the more generalist botanists,
biologists, and physicians. Their findings gave medical science a
more reductionist and technically more effective turn.

Changes in American medical practice reflected the gradual
acceptance of recent developments in Europe. Starting in the
1870s, American physicians flocked to the famous laboratories of
German and Austrian universities for a year or more of study — if
they were ambitious and could afford the expense of travel and
living abroad without income. Between 1870 and the outbreak of
World War I in 1914, about 15,000 American physicians studied
medicine in Germany alone. ^^

While most American doctors who studied in Europe re-
turned to develop lucrative private practices, a few put their main
energies into developing laboratory medical sciences in the
United States. Carl Ludwig's physiology institute in Leipzig
produced several luminaries of America's infant medical science.
Henry Pickering Bowditch, one of Ludwig's pupils, founded the
country's first experimental physiology department at Harvard
University in 1871. William Henry Welch, another of Ludwig's
pupils, started America's first pathology laboratory at Bellevue
Hospital medical school in 1878.^°

Fifteen years later American medical science came of age with
the opening of the Johns Hopkins medical school, modeled after
the German university medical schools with a heavy emphasis on
research in the basic medical sciences. At Hopkins, for the first
time in the United States, the laboratory science faculty were to
be full-time teachers and researchers, supported by salaries
adequate to live on and unencumbered by the distractions of
private practice. Virtually the entire Hopkins faculty was trained
in Germany. Hopkins, and then Harvard, Yale, and Pennsylva-

Scientific Medicine I I 73

nia, became the indigenous producers of scientific medical
faculty. As scientific medicine gained increasing acceptance,
medical schools throughout the country vied for Hopkins gradu-
ates to add gleam to their lackluster local faculties.

Medical practice likewise began to change with the increased
acceptance of medical science. Physicians began introducing into
their work those scientific medical practices that were uncompli-
cated and acceptable to their patients and at least seemed
effective in reducing suffering and ameliorating the symptoms of
disease. ^^ The use of bleeding and calomel began falling off in the
1870s though many physicians continued to use them on a more
hmited basis as late at the 1920s.

Physicians who had the money to take an extra year's study in
Europe were able to build more prestigious practices than the
ordinary American-trained doctor. Usually they would take
themselves out of direct competition with the majority of
physicians by specializing in gynecology, surgery, opthalmology,
or one of the other new branches of medicine. They quickly
formed a new elite in the profession, with reputations that
brought the middle and wealthy classes to their doors. ^^

As the base of scientific medicine spread out to include more
practitioners, the peaks of elite physicians rose even higher. They
quickly found that "scientific medicine" not only seemed more
effective than the heroics of old, it was also far more profitable.

Professional leaders had tried numerous ways of uplifting the
profession during the nineteenth century, but none of them had
succeeded. It was medical science that provided the key to
professional reform. Medical research yielded new tools of
understanding and held out the hope of more effective techniques
of prevention and treatment than orthodox medicine offered. But
scientific medicine was utilized by professional leaders beyond
merely increasing the technical effectiveness of their practice. It
became as well the ideology of professionalization, used to gain
support from the dominant groups associated with industrial
capitalism, to cement the complete dominance of health care by
the medical profession, and to raise the incomes and status of
physicians as a group.

The obvious advantages to the profession notwithstanding,
scientific medicine contained within it the seeds of ultimate
destruction for the profession. The remainder of this chapter and

74 I Scientific Medicine I

the rest of this study will examine how this dialectic played itself
out — the benefits the profession derived from the adoption of
scientific medicine, the contradictions inherent in this historical
process that began to undermine the position of the medical
profession, and the new forces and contradictions that are now
emerging.

GAINING PUBLIC CONFIDENCE

Scientific medicine solved two broad problems the medical
profession faced in the late nineteenth century: lack of public
confidence in the effectiveness of their service and competition
within the medical profession.

Rather than inspiring awe and confidence, the regular medical
profession had won the public's fear and ridicule. To win public
support and patronage was the major task set by professional
leaders during the nineteenth century. The AMA's code of ethics
sought to assure the lay public that doctors were ethical and
competent and attempted to command the public to place their
confidence in regular physicians. But no claims or commands
were effective in the absence of convincing personal experience
or persuasive propaganda that could substitute for personal
experience.

While homeopathy, eclecticism, and osteopathy did not have
as much public patronage as the regular profession, they had a
strong base of support. They had a following, including many
wealthy and influential people, who believed in their absolute
effectiveness. Their practitioners were widely believed to be,
relatively at least, as effective as and certainly less dangerous than
most regular doctors. And they did not demand a monopoly of
practice, a wise and practical political course given the disreputa-
ble condition of the profession and the almost universal reliance
on home remedies for most minor acute and chronic ailments.

For the regular profession to win in their competition with the
other medical sects, they needed first of all to gain absolutely and
relatively in public confidence. Scientific medicine provided the
basis for a concerted and successful campaign to win this public
support. The effort never depended on the common folk of
America. The campaign for acceptance of scientific medicine was
aimed at the wealthy and powerful in society and the new

Scientific Medicine I I 75

"middle" classes. Both of these groups owed their privileged
positions to the intensive industrialization that began with the
Civil War. They were particularly attracted to a kind of medicine
that shared their industrial culture, their values, their world
outlook, and their ideologies. "Scientific management" analyzed
the labor process in production into its constituent elements and
reorganized them under management's control and for manage-
ment's profits." In a similar vein, "scientific medicine" analyzed
the body into its parts, subjected the parts to the control of
scientific doctors, and thereby kept the bodies healthier and more
efficient.

The germ theory of disease was especially attractive to both
the regular profession and these new industrial and corporate
elites. The germ theory emphasized discrete, specific, and exter-
nal causal agents of disease. It gave encouragement to the idea
of specific therapies to cure specific pathological conditions. ^"^
The payoff for the medical practitioners would be increased
technical effectiveness and improved standing in the eyes of the
public. That was not the foremost concern of either influential
capitalists or medical researchers. These men (there were hardly
any women in their ranks) saw in scientific medicine the possi-
bility of preventing diseases through technological intervention
that identified the offending organism and its means of contagion,
and attacked the organism at the source or used it to create an
immune response within the body. Disease was thus seen as an
engineering problem, surmountable with sufficient talent and
resources. To the medical researchers the germ theory and dis-
coveries in bacteriology confirmed the value of their craft and
assured increased support for their work. For capitalists, bac-
teriological investigations and the application of the findings
opened the possibility of reducing the toll that disease took of
society's resources.

The forerunners of scientific medicine, along with practition-
ers in other medical sects, had already greatly improved the
classification of diseases. European physicians had long dominat-
ed the field of medical discovery although now and then an
American made a contribution. In 1836 William Gerhardt, a
physician at Philadelphia Hospital, clinically differentiated ty-
phoid from typhus. But there was little practical benefit from
such classifications when no therapy was forthcoming to cure the

16 I Scientific Medicine I

condition. Bleeding, purging, blistering, and tonics were the
standard bag of tricks available to regular physicians. Homeo-
paths and eclectics, along with lay healers, used a wide assort-
ment of herbs, and many claimed high rates of cures. By the
1880s the regular profession still had only a few drugs that were
widely recognized to be curative: Quinine could save the victim of
malaria, mercury could cure syphilis, and digitalis was often
successful in treating heart disorders. ^^

The field of disease prevention was somewhat more success-
ful. In the eighteenth century weahhy Europeans and Americans
adopted the practice of variolation, a somewhat dangerous
inoculation against smallpox used in the East for centuries. In
1798 Edward Jenner introduced inoculation with cowpox that was
effective and somewhat safer than variolation.^^

By the time of the third major cholera epidemic in the United
States in 1866, the notion that cholera was a specific and con-
tagious disease had finally won near-unanimous support from
the medical profession, joining the already strong popular belief
in its contagion. Medical support for cleaning up the accumulated
fihh in American cities won the backing of the business class and
helped prevent the spread of cholera and the high death rates that
had characterized the previous epidemics. The success of this
preventive effort was credited to sanitary engineering and
brought increased support for sanitation programs. ^^

Despite the scant results, leading practitioners and the new
class of medical researchers sustained their faith in the eventual
success of medical science. The major breakthroughs came from
Europe in the 1880s and 1890s. In 1883 and 1884 Edwin Klebs
and Friedrich Loeffler isolated the germ involved in diphtheria, a
major killer in the nineteenth century. Emil von Behring and his
coworkers produced a diphtheria antitoxin in the early 1890s,
which although of little significance in reducing the death toll
from diphtheria, supported the belief that deadly epidemics that
were borne with resignation could in fact be prevented by
understanding their causes.^®

These and other discoveries in the 1880s and 1890s were
lauded around the world. Medical science benefited with new
respect and political and financial support. Success indeed paved
the road to fortune. The German government provided laborato-
ries for Robert Koch and Paul Ehrlich. In France popular

Scientific Medicine 1/77

contributions supplied a research institute for Louis Pasteur. In
England and Japan private philanthropy paid for new medical
research institutes.

In the United States private and government support for
medical research lagged behind these other countries. Veterinary
medicine received help from the Department of Agriculture to
stem epidemics that were wiping out livestock investments.
Government officials and philanthropists saw little value in
researching human disease, as Richard Shryock notes, ''partly
because of the nature of medical science prior to 1885 and partly
because human welfare brought no direct financial return. Hogs
did."-'' Discoveries of the 1880s and 1890s, however, held out the
promise that as science uncovered the germs that caused the great
pestilences, further investigation would provide not only cures
but methods for guarding against infection and for preventing the
spread of epidemics. These expectations guided the lives of
medical researchers, but they were also spreading rapidly among
the middle classes and those who owned and managed America's
new industrial empires.

Medical science rescued the medical profession, in particular
the practitioners, from the widespread lack of confidence in their
effectiveness. These few but significant discoveries, mostly in
bacteriology, increased the belief in the technical effectiveness of
the profession as a whole. The actual impact of progress against
infectious disease was not nearly so great as its proponents
claimed. The arsenal of effective weapons against diseases did not
increase spectacularly, but its limited advances did provide the
basis for persuading the public that scientific medicine reflected
on all members of the profession — practitioners as well as
researchers — who had been trained in the theory and methods of
scientific medical research.

The slight increase in the effectiveness of the new medicine
was embellished in propaganda by the profession and the media.
From the 1890s on, popular magazines and newspapers joined the
leading medical journals in praising the accomplishments and
prophesying the future success of medical science. Articles
ridiculing "Popular Medical Fallacies" and extolling the "Tri-
umphs of Modern Medicine" and the "War Against Disease"
appeared in many popular magazines as well as professional
journals. They portrayed medicine as an "exact science" and the

78 I Scientific Medicine I

physician as an inquiring and skeptical scientist who avoids "hasty
jumping at conclusions or too-ready dependence upon formu-
lae. "^°

The increased credibility of medicine was important in
convincing the public that doctors with scientific medical training
had an expertise worth paying for. If doctors could do little more
for a patient than an herbal healer or a patent medicine, there
was not much point in people wasting their money on expensive
doctors' fees. Scientific medicine wrapped the modern doctor in
an aura of therapeutic effectiveness, and the limited improve-
ments gave support to that aura. Furthermore, the technical
expertise associated with scientific medicine helped to mystify the
role and work of the physician more effectively than did older
notions of the etiology of disease, unpleasant remedies, and
transparent codes of "ethics." Scientific medicine thereby sup-
ported the claims of the profession for a monopoly of control over
all heahng methods. These benefits provided the basis for other
gains and were effective in undermining sectarian medicine,
midwifery, and other forms of competition.

In seeking to destroy its competitors' hold on the medical
marketplace, the regular profession proffered scientific medicine
as more effective than "medicine as art" and "sectarian medi-
cine" and "quacks." Not only was it more effective, it was, as
each sect before it had claimed, the only truly valid medicine.
Scientific medicine was held up as the nonsectarian medical
theory and practice — the only one based not on dogma but on
verifiable truths. ''^ As the only valid medicine, it should be
granted a monopoly of practice; "none but men and women who
have an interest in scientific medicine" should be allowed to join
any county medical society.*^ But making the claim was not
equivalent to having it accepted.

Folk medicine was still widely used in the United States,
particularly in the countryside but also in the cities. Every family
had its traditional remedies that were part of the family lore,
believed in and passed down from generation to generation.
Generally, the young woman's own family's remedies prevailed
in her new family. "^^ Some of the remedies undoubtedly acted as
placebos, but many were certainly effective in providing rehef
and even cures. Such traditions were effective obstacles to the
acceptance of scientific medicine.

Scientific Medicine I I 79

Most practitioners were also very pragmatic, developing a
repertoire of skills and utilizing some new techniques that seemed
effective and readily accepted by their patients. These country
and city doctors were not much impressed by medical science.
They saw it as a tool enabling them to heal more effectively when
its claims worked and when its techniques did not require a whole
new method of practice.

Robert Pusey, a Kentucky country doctor who practiced in
the 1870s and 1880s, used the clinical thermometer, assorted
specula, and a syringe. Occasionally, he used the stethoscope
although he preferred to place his ear to the patient's chest. With
this simple method he could hear and distinguish most conditions
as well as his scientifically trained son could with a stethoscope.
He used judgments based on practice, read up on cases in the
more concrete and concise medical texts, and distrusted journal
articles. The older Dr. Pusey vaguely accepted bacteriology,
especially as an explanation for infections causing pus but not
generally for infectious diseases. He sometimes used calomel,
made and sold his own drugs, did not use patent medicines, and
often prescribed strichnine and arsenic as tonics. He practiced
surgery in which he used chloroform as an anesthetic and asepsis
when the knowledge and techniques became available to him."^"*

The propaganda for scientific medicine was sure to be
effective, but it would take time. John Shaw Billings, a leading
medical reformer in the late nineteenth century, observed that
doctors whose practices were not interfered with by quacks were
indifferent to reforms while those in need of larger practices were
more indignant about such competitors. Many quacks had
effected cures where science had failed, Billings admitted. But
rather than giving him pause in his rejection of any but scientific
medical methods, Billings saw it as a tactical problem of
persuading the American public that it is in their interests to
suppress quackery. The remarkable achievements of medical
science were being brought to the public, but, Billings cautioned,
"it is necessary to go slowly and allow such evidence to
accumulate. '"^^

The reformers believed scientific medicine would increase the
technical effectiveness of the medical profession, and they
promoted it as the only effective therapeutic method. Through
propaganda they hoped to undermine public resistance to its use,

80 I Scientific Medicine I

increase the public demand for it, and thereby force practitioners
to join the new "nonsectarian'' medicine.

REDUCING COMPETITION

As scientific medicine won public and professional credibility,
it also solved the second and fundamentally more serious
problem facing the profession in the nineteenth century: competi-
tion.

Plagued by competition among numerous medical sects,
between practitioners and medical school faculty, and within the
"crowded" ranks of regular practitioners themselves, the profes-
sion was saved from its own internal competitive struggles by the
triumph of scientific medicine. First, the technical requirements
of teaching scientific medicine provided several advantages for
the profession's elite. Second, scientific medicine forged new
unity in the interests of elite practitioners and medical school
faculty. Third, as it gained increasingly widespread legitimacy,
scientific medicine undermined the major medical sects. It
thereby imposed unity among those sects in their subordination
to the dominant forces in the profession. And, finally, medical
science made possible specialization which was largely a response
to competition within medicine. The overall impact of scientific
medicine within the profession was to legitimize control by elite
practitioners and medical school faculty.

TECHNICAL REQUIREMENTS OF
SCIENTIFIC MEDICAL EDUCATION

THE NEW ACADEMICIANS

Making the doctor the purveyor of a broad range of skills
within a context of mystified knowledge required extensive and
esoteric training. Nineteenth-century medical reformers envi-
sioned the physician as a bedside scientist. Medical practitioners
must think and talk like scientists. They must be trained in
anatomy, physiology, bacteriology, pathology, pharmacology,
and the physical sciences. They must think of health and disease,
not holistically as general relationships between bodily systems or

Scientific Medicine I I 81

between the person and the environment, but in terms of the
micro-concepts of physiology and anatomy, bacteriology and cell
pathology. These sciences and their reductionist concepts were
gradually recognized in the late nineteenth century as the
foundations of medical education.

The medical schools of the last century were staffed by
practitioners, often very talented men who were heavy on the
"art" but less expert on the "science." Increasingly, laboratory
science courses were taken away from the local practitioner and
given to physicians with special training in the laboratory
sciences. The new academic physicians who preferred these
laboratory sciences over medical practice prospered with the
increased demand for more faculty with training in these fields.
Those who could afford to spend a year or two studying in
Germany or Austria after medical school had secure, if not
lucrative, academic careers awaiting them on their return.

In 1893 Johns Hopkins became the first medical school in the
United States to employ these laboratory men full time and to
pay them salaries that enabled them to devote all their time and
energy to research and teaching. The new full-time organization
of the laboratory science faculty was hailed as a great advance for
American medical education. It was quickly adopted by other
elite schools and gradually became the norm emulated by the
average institution. Although the laboratory science faculty gave
up private practice incomes of $10,000 a year and more in return
for salaries of $3,000 or $4,000, there were more than enough
people to fill the demand. "^^

Some of the giants of medical reform, like William H. Welch,
loathed medical practice, feared the insecurity of competition
among private practitioners, and longed for the opportunity to
pursue medical research without the diversions of maintaining a
private clientele. Before going off to Europe in 1876 to advance
his medical science skills, Welch confided to his sister his fears of
trying to set up "by hook or by crook a patronage of some kind."
Echoing the pipe dreams of most medical graduates, Welch
observed, "it is much finer to hold a chair in a medical college,
and to have a salary . . . and to be sought by patients instead of
seeking them." His studies abroad would give him a jump on his
competitors: "If by absorbing a little German lore I can get a httle

82 I Scientific Medicine I

start of a few thousand rivals and thereby reduce my competitors
to a few hundred more or less, it is a good point to tally.'"*''

The emphasis on scientific medicine thus created unprece-
dented job opportunities for physicians qua medical scientists. As
positions expanded, a core of professionals developed who were
more dedicated than ever to seeing medicine as science complete-
ly displace medicine as art. These medical scientists' interests and
identification were bound up solely with medical schools and
not with private practice. As the vanguard of the profession's
successful strategy and the recipients of millions of dollars in
capital investments in medical research and education, the new
medical academicians became the symbol of the new profession.
In the 1890s, for the first time in the United States, the medical
profession came to exalt the scientist over the practitioner. "**
Despite their more modest, middle-class incomes, the scientists
were the new elite in the profession.

The faculty at the most prestigious schools won their profes-
sional reputations on the basis of their research contributions to
their fields. The best reputations attracted the best students and
the wealthiest patients. In 1903 Wilham Halsted, a famous sur-
geon on the Johns Hopkins faculty, got $10,000 for an appendec-
tomy, and his colleague, Howard Kelly, charged $20,000 for a
major operation."*^ Unlike the old-time medical faculties, whose
material interests were enhanced by student fees and referrals
from their many former students, the new academicians' mate-
rial interests were tied to the promotion of medical science. It
was in their interests to raise the standards of medical schools
and to make scientific medicine the only acceptable theory and
practice.

The predominant type of medical school, owned by the
faculty and existing on student fees, prospered as long as
enrollments could be kept high and costs low. However, practi-
tioners would prosper only if the production of physicians was
decreased, reducing competition within the profession. This
conflict of economic interests had divided elite practitioners from
medical school faculty throughout the nineteenth century. The
ascendancy of scientific medicine transformed the old conflict
into the basis for an alliance between the scientific medical
faculties and elite practitioners.

Scientific Medicine I I 83

The interests of the new medical scientists in medical educa-
tion were thus tied to the dominance of scientific medicine and
not to large numbers of students or even large numbers of
medical schools. They joined the elite practitioners as the leaders
of reform in the profession. Together they gained control of the
AMA at the turn of the century and completely reorganized it to
make the AMA the profession's instrument of political action as
we know it today and to use it and the leading medical schools to
alter completely the technical, economic, and social forces within
the medical profession.

The technical requirements of developing and teaching scien-
tific medicine sharpened the distinction between laboratory
science faculty and practitioners, provided new and expanding
job opportunities for medical scientists, and hoisted them to ehte
and influential positions within the profession. At the same time
these developments provided the basis for the aUiance between
these new elite faculty and the elite practitioners, giving them
sufficient power to take control of the profession and transform
it.

"fewer and better"

As a professional consensus developed around scientific
medicine, the scientific medical faculty and elite practitioners
agreed upon "objective" criteria for judging medical schools. The
needs of scientific medical education were pretty clear cut. If
students are to be trained as medical scientists, they need to be
taught the biological and physical sciences, and they need to be
taught how to apply the principles they learn in those sciences to
the diseases of real people. Experience as well as common sense
argued for laboratory courses in the sciences and hospital
experience for the clinical appHcation of those sciences: Learning
how is at least as important as learning about.

The technical requirements of teaching scientific medicine
suggest fairly clear criteria for judging medical schools. If the
premise of training scientists is accepted, then any worthy
medical program must have adequate laboratory facilities, clini-
cal teaching facilities, and well-trained laboratory and clinical
faculty.

While the criteria of what is "adequate" might be (and were)

84 I Scientific Medicine I

argued, the standards were set by those who secured positions of
power. The AMA became the vehicle for poHtical action within
the profession and the larger society. The reformers used the
technical requirements of training medical scientists to set
standards and then evaluate medical schools according to those
standards. With a few exceptions — Johns Hopkins the shining
example among them — virtually all nineteenth-century medical
colleges were weak when judged by these standards.

Unquestionably, scientific medical education was and is an
expensive affair. The capital outlays for laboratories and hospital
facilities were beyond the resources of most nineteenth-century
and early twentieth-century medical schools. Student lecture fees
could not cover the larger salaries for faculty who devoted
substantial time to research and teaching, let alone the increas-
ingly widespread full-time salaries for laboratory science faculty.
No medical school could exist on student fees and at the same
time provide these increasingly necessary medical science pro-
grams for their students.

In some states, students who graduated from medical colleges
that did not have these programs, facilities, and personnel were
barred from taking licensing examinations. Increasingly, state
exams were geared to the information and perspectives provided
in scientifically oriented schools, and graduates of inadequately
equipped schools failed their licensing exams with increasing
frequency. ^° Since the schools were supported by students' fees
and students had little incentive to attend a school that did not
prepare them to pass state board exams, inadequate schools lost
out in the competitive market for enrollees and their money.
AMA president Charles Reed observed in 1901, "Under the
pressure of legal requirements the weight falls with almost fatal
force upon the small, private and poorly equipped institutions."^^
The technical requirements of scientific medical education thus
brought about the conditions of collapse of proprietary medical
schools. As Abraham Flexner later noted, "Nothing has perhaps
done more to complete the discredit of commercialism than the
fact that it has ceased to pay. It is but a short step from an annual
deficit to the conclusion that the whole thing is wrong anyway.""

In Chapter 4 we will see how these conditions provided an
opportunity for the AMA and capitalist foundations to transform
medical education in the United States. For the moment it is

Scientific Medicine I I 85

enough to note that without sufficient capital and endowments,
no medical school could survive in the era of scientific medicine.
Schools collapsed and consolidated all over the country beginning
in 1905, coinciding with the first year of serious activity by the
AMA's new Council on Medical Education. Between 1905 and
1910, thirty schools merged and twenty-one closed down alto-
gether." The number of medical schools declined from a high of
166 in 1904 to 133 in 1910, 104 in 1915, and hit a low of
seventy-six in 1929. In the reorganization of medical schools the
number of students was reduced at many institutions in order to
intensify the teaching and research resources within each school.
Thus the technical requirements of scientific medical education
were used to close schools and decrease the production of new
physicians, easing the competition within the profession and
raising doctors' incomes.

Furthermore, scientific medical education "required" greater
prehminary education. Students must come to medical school, it
was argued, having had a full year each of college chemistry,
physics, and biology.

The demands for stringent requirements of preliminary edu-
cation were not new to the era of scientific medicine. In eigh-
teenth-century and nineteenth-century England, where "physi-
cians" were a tiny elite above surgeons and apothecaries, it was
essential for physicians to be regarded as gentlemen. Because
they practiced only among the wealthy, it was important to their
pocketbooks to be able to mingle with the upper class. As
professions developed, a liberal education became the mark of
upper-class origins. "It might not make you a gentleman," W. J.
Reader has observed, "but without it a gentleman you could
hardly hope to be."^"^ In the United States as well, a college
education was the mark of a gentleman. For those who were not
born into a privileged class, a college education — if it could be
gotten — "rubbed the raw edge off many a country boy," giving
them sufficiently proper appearances to make their way to a
higher social class. ^^

It is not surprising then that substantial educational require-
ments had been declared an imperative in the mid-nineteenth
century because it would assure that doctors would be gentlemen.
Daniel Drake, probably the most illustrious American physician
of the midcentury, criticized his colleagues' ignorance of Latin

86 I Scientific Medicine I

and Greek without which, "whatever may be his genius and
professional skill," a physician would still necessarily "appear
defective and uncultivated."^^ This persistent concern was echoed
by Johns Hopkins' famous Dr. Welch who wrote in 1906, "The
social position of the medical man and his influence on the
community depend to a considerable extent upon his preliminary
education and general culture."^''

Elite physicians frequently complained of the "coarse and
common fiber" of much of the profession. ^^ Even a minority of
the profession lacking upper-class polish cheapened the status of
all doctors. The proliferation of inexpensive proprietary schools
enabled a young man to live at home while attending medical
school and thereby made medicine a ladder that some farm boys,
artisans, and shop clerks could climb to middle-class status and
income. It was not only the inadequacies in the training provided
in commercial colleges that angered the elite reformers; it was
also whom they brought into the profession. Frank Billings, in his
presidential address to the AM A in 1903, disdained "these
sundown institutions" that provided evening classes and enabled
"the clerk, the streetcar conductor, the janitor and others
employed during the day to earn a degree. "^^

Prior to the acceptance of scientific medicine, attempts to
lengthen the medical school term of instruction and raise pre-
liminary education requirements were met with charges of
elitism. "There is an aristocratic feature in this movement" by
medical societies, Martyn Paine, a faculty member in the New
York University medical department, asserted in 1846. "It is
oppression towards the poor, for the sake of crippHng the medical
colleges. "^^

Even after the turn of the century some education leaders
warned against excluding the poor from medicine. In 1908, W. L.
Bryan, president of Indiana University, criticized the Association
of American Medical Colleges' proposed requirement of two
years attendance at a liberal arts college prior to admission.
Raising the entrance requirement would "shui out of the medical
schools thousands of men who are not ignorant nor incompetent"
but who would be excluded because "poverty and other hard
conditions" have kept them from the colleges. ^^ The profession's
objective was exactly that — to exclude the poorer classes from
their ranks.

Scientific Medicine I I 87

Scientific medicine provided an "objective" basis for requir-
ing a lengthy preliminary education. If students had to come
prepared with college courses in physics, chemistry, and biology,
then there could be no argument against lengthening the require-
ments. The standard-setting schools raised their requirements
from completion of high school to two years of liberal arts college
and finally to a bachelor's degree. From the moment it opened its
doors in 1893, Johns Hopkins medical school led the way by
requiring a bachelor's degree for admission and four years of
instruction for its prestigious M.D. degree. When Harvard
instituted the baccalaureate requirement in 1901, its entering
medical class dropped from an all-time high of 198 students the
previous year to sixty-seven.^^ The preliminary education re-
quirements were several steps ahead of the great majority of
American youth and enabled the profession to draw its recruits
from the "better" classes.

Was this an unintended outcome of the technical "require-
ments" of medical education, or was it the desired outcome for
which scientific medicine provided the mere rationale? Given the
goals of professional leaders throughout the nineteenth century
— to reduce the numbers of physicians and to raise the social-
class standing of the profession— it seems that scientific medicine
provided the credible rationale that all previous generations of
medical elites had sought in vain. The preHminary requirement
would weed out the economically and socially "unfit." Some
reformers justified this selectivity by the cost of scientific med-
ical education. "It does not pay to give a $5,000 education to
a $5 boy," intoned John Shaw Billings in 1886 while helping to
organize Johns Hopkins medical training." But most elite physi-
cians simply desired to eliminate "professional degeneracy," as
Dr. Inez Philbrick put it at the turn of the century. Philbrick, a
successful practitioner in Lincoln, Nebraska, rallied his colleagues
to "Let fewer and better be our motto. '"^^

In sum, the technical requirements of scientific medical
education gave new career opportunities to physicians as medical
scientists, creating a whole new position of full-time researcher
and teacher and a new group of elite medical school faculty who
combined a material interest in medical schools with a commit-
ment to promoting scientific medicine. At the same time these
technical requirements of the new medical education provided

88 I Scientific Medicine I

the standards and the rationale for reducing the output of medical
schools and raising the social class base of the entire profession.

"NONSECTARIAN" MEDICINE
UNDERMINES THE SECTS

As scientific medicine gained increasingly wide acceptance, it
undermined the other medical sects. Scientific medicine thereby
forged unity within the profession by enabling the AMA to
subordinate the sects to its own standards of medical education
and practice. Overwhelmed by the increased claims of technical
effectiveness for scientific medicine, the major sects began
incorporating scientific medicine into their own doctrines and
practice.

Homeopathy, the most formidable competitor of the regu-
lar professions in the nineteenth century, gradually dropped its
unique features. Most homeopathic physicians in America broke
with pure homeopathic theory in the mid-nineteenth century,
taking what they believed valid from regular medicine and
discarding especially heroic therapies. They purged the purists
from their ranks by founding homeopathic medical colleges,
previously believed unnecessary, and requiring training in gener-
al medical skills, including surgery. ^^ Most midcentury American
homeopaths were regular physicians unhappy with the ineffec-
tiveness of regular medicine and with its growing unpopularity. In
1849, 1,000 Ohio physicians and lay people, disaffected by the
orthodox profession's inability to reheve suffering during the
cholera epidemic, organized a homeopathic society in Cincin-
nati.^^

The direct competition that homeopathy posed to regular
physicians led to campaigns to exclude them from medical
societies and hospital privileges. The Massachusetts Medical
Society began excluding homeopaths in 1860. By the 1870s there
was a general attack, led by the AMA, on homeopathy and other
"exclusive systems of medicine." Physicians violated the AMA
code of ethics if they consulted with sectarian physicians or
female or black doctors. In the 1870s the restrictions against
female physicians were rescinded under pressure from the
growing women's rights movement, and the exclusion of blacks
was relaxed though local medical societies and hospitals openly

Scientific Medicine I I 89

continued their racist practices. But the attacks on "irregular"
doctors continued throughout the century.^''

By the end of the nineteenth century, nearly all homeopaths
were using both regular and homeopathic drugs. Leading homeo-
paths announced that the great majority of homeopathic doctors
did not beheve in infinitesimal doses, rejected the universality of
the law of "like cures Hke," and generally used drugs like regular
physicians. Homeopaths also became interested in clinical spe-
cialties. In 1899 the American Institute of Homeopathy redefined
a homeopathic physician as "one who adds to his knowledge of
medicine a special knowledge of homeopathic therapeutics."^®
Homeopathy, as well as other sects, were being overcome by the
competition from scientific medicine.

Nonetheless, the continued popularity of homeopathy and
eclectic medicine and the incomplete acceptance of scientific
medicine made it difficult for regular professional leaders to win
exclusive licensing privileges in the states. With the convergence
in practice and education of homeopaths, eclectics, and regular
physicians, it was possible to assure the dominance of scientific
training and politically necessary to ignore, for the moment, the
sectarian separations. Only through the combined efforts of the
regular and "irregular" profession could laws be secured to
restrict medical practice to scientifically trained physicians. The
profession's leaders around the country agreed with William
Osier, the most eminent American physician of his day, who
advised the Maryland state medical society in 1891, "if we wish
legislation for the protection of the public, we have got to ask for
it together, not singly. "^^ And together they asked.

Beginning in the 1870s, state legislatures established medical
Hcensing examination boards. In 1873 Texas passed the first
modern medical practice act, a morale-boosting victory to the
profession that offset the bitter memories of the Jacksonian era's
repeal of licensure. The Illinois Board of Health, the state's
licensing agency, was a model for the nation. Beginning in 1880,
it began to hst American and Canadian medical schools according
to qualitative criteria set by the Association of American Medical
Colleges, an organization of elite, scientifically oriented institu-
tions. ^°

Nonregular doctors participated in some way in medical
licensing in at least thirty-three of the forty-five states that had

90 I Scientific Medicine I

enacted licensing laws by 1900. Physicians from at least two sects
served on the same licensing boards in twenty states.^' By
cooperating in licensure, the nonregular profession won inclusion
among the respectable. With scientific medicine gaining ground
every year, it appeared to the leaders of homeopathy that they
had nothing to lose and everything to gain from their association
with the regular profession. The president of the AMA even
acknowledged in 1901 that "with broadened and increasingly
uniform curricula" it made little sense to argue that competing
sects did not share the profession's competence. '-

The reform leaders in the regular profession won the biggest
rewards. By cooperating with the nonregular sects, they won
licensing laws that recognized scientifically oriented reforms as
the only valid basis of medical education. In a short time they
secured complete control of licensing and the resources for
medical education reform. Whether these elite professionals
foresaw their ultimate gain from cooperating with the homeo-
paths and eclectics or they were guided by expedience undiluted
by strategy, the cooperative licensing efforts hastened the
elimination of sectarianism amid the growing chorus of support
for scientific medicine.

By 1903 the AMA adopted the strategy explicitly. At its
annual convention the delegates voted to eliminate the decades-
old exclusion of physicians who were trained as homeopaths or
eclectics but chose not to "designate" themselves as such.''^ Two
years earlier AMA president Charles Reed had drawn attention
to the good effects of allowing all licensed physicians into state
medical societies. By ending its exclusionary policy, he said, the
New York society had reduced the registration of sectarian
physicians by "nearly ninety percent."'"*

Scientific medicine was perhaps more effective than homeo-
pathy and eclecticism in treating some diseases for which it had
developed cures, but it was not, particularly at the turn of the
century, the panacea it was believed to be. The reformers' overly
optimistic assessment is shared by many contemporary medical
historians. WiUiam Rothstein, for example, maintains that "sects
could survive in medicine only so long as medically valid
therapies constituted a smnU part of the therapies used by
physicians. Once medically valid therapies became the dominant

Scientific Medicine I I 91

part of medical practice, medical sectarianism declined marked-
ly."'^

In reality the number of medically effective therapies had not
increased significantly in the first few years of this century, the
period when sectarianism declined in medicine.''^ Rather the
campaign to win acceptance for scientific medicine struck a
responsive cultural chord among the new technical and manageri-
al groups associated with industrial capitalism and with the media
they controlled. The campaign established a popular belief in the
broad effectiveness of scientific medicine and, together with
political action by elite medical reformers, undermined the
medical sects that competed with the regular profession.

SPECIALIZATION: LESS COMPETITION FOR THE ELITE

Advances in medical science during the late nineteenth
century rapidly developed the technical basis for some physicians
to offer highly specialized expertise not available from the
ordinary practitioner. Medical advances were presumably usable
by any physician, but in reality only those who studied a
particular area developed the expertise to apply techniques and
inventions. The ophthalmoscope, invented by Helmholz in 1851,
required considerable study and practice to know what to look for
on the other side of the cornea. Anesthetics, antisepsis, and
asepsis made surgery a relatively safer procedure, but the masters
of surgical techniques were those who devoted their entire
practice to it.

The very existence of medical specialization rested upon a
reductionist analysis of the body and disease. Its concrete
development was made possible by advances in medical science.
Nevertheless, specialization among practitioners was encouraged
by economic competition within the profession and grew to take
advantage of the new market for more technical, seemingly, more
scientific medical services.

With dissatisfaction rampant among more ambitious members
of the profession, some 15,000 American physicians studied
medicine in Germany alone. They returned to reap the benefits
of their advanced training and confidence to specialize in some
branch of clinical medicine. '"^ Successful specialists soon earned

92 I Scientific Medicine I

more than twice as much as the better-off general practitioners.''*
Elite, scientifically oriented physicians saw specialization as a
solution for themselves in the competitive medical market.

The demand for specialists grew with the urban upper middle
class. Patients whose own social position was based on the growth
of technology and industrialization sought out physicians whose
practice suggested the same world view. Gynecological theory
viewed most female disease as being rooted in or associated with
uterine problems. As Barbara Ehrenreich and Deirdre English
have amply demonstrated, Victorian femininity itself was associ-
ated with invahdism and physical and emotional frailty. Women
of the "better" classes were defined as sick in order to support
their role as social ornamentation, demonstrating the financial
and social success of their husbands and distinguishing them from
lower-class women who were expected to work and were
considered sickening.''^

Gynecological surgeons preyed upon the supposedly delicate
nature of upper middle-class women and the terrible consequenc-
es of having a "tipped" uterus or sexual appetite. Hysterecto-
mies, ovariotomies, and cliteridectomies were prescribed for
these and other female maladies. Some gynecologists, like
Horatio Bigelow writing in the AMA Journal in 1885, favored a
"conservative" approach over too rash use of the knife or
mechanical devices. He believed that better results could be
obtained "by attention to every detail of life, even the most
insignificant, for the aggregation of the little things go to the
making of the big ones, and also, by attention to psychical
conditions and reactions. "*° Such attention, of course, required
daily visits from the doctor.

Gynecologists tailored their medical theories to the prevailing
notions of the place of women in society and thereby developed a
new and lucrative medical market. Upper-class women became
the objects of knife-wielding gynecological surgeons or the
invalided captives of overly "attentive" gynecological practition-
ers. From the early 1890s abdominal and pelvic surgery seemed
the profession's own Gold Rush, and surgeons were, in the words
of the AMA Journal, "as restless and ambitious a throng as ever
fought for fame upon the battlefield."**

General practitioners obviously suffered to the extent that
their patients went to specialists with complaints the GPs

Scientific Medicine I I 93

formerly treated. From the 1850s onward, the GP-dominated
medical societies attacked what they viewed as unfair competi-
tion. In 1874 the AMA's judicial council ruled that specialists
could advertise only that their practices were ''limited to diseases
peculiar to women" or "diseases of the eye and ear." Such
restrictions on specialists denied the claims of scientific leaders
that specialism was based on greater expertise not available to the
general practitioner. Moreover, few physicians at that time could
completely limit their practices to specialties since specialization
was not yet widely enough accepted.*^

Conditions soon changed, at least in large and medium-size
cities. Specialists promoted the medical sciences through their
own societies. Following a rebuff by the AMA, which named a
committee of medically conservative professionals instead of
distinguished medical scientists to host the 1887 International
Medical Congress, specialists and other medical scientists formed
the Association of American Physicians. In 1888 all national
specialty societies formed an alliance outside the AMA in the
American Congress of Physicians and Surgeons. In the last years
of the nineteenth century, as scientific medicine increased and the
economic base of specialism grew more secure, membership in
scientific societies increased — particularly in Eastern cities where
medical centers were beginning to dominate medicine — while
membership in the AMA languished.*^

Medical specialty societies were intended not only to promote
development of the specialty but also to gain acceptance of the
specialists by general practitioners. Even though they were
competitors, specialists relied heavily on referrals from other
physicians for much of their practice. GeneraUsts had to be
induced to refer their difficult cases to other physicians. To
encourage referrals, many, if not most specialists, gave a portion
of their fee to the doctor who made the referral. *"* Fee-splitting
became a widespread practice to control competition and gain
acceptance of specialists by GPs.

Fee-splitting, however, was a private tool of individuals used
to soften competitive relations among themselves. For fee-
splitting to be used collectively by the organized profession would
require an open admission of its existence and legitimacy within
the profession. That would have been worse than the competition
that fee-splitting was attempting to regulate because it was a

94 I Scientific Medicine I

purely commercial arrangement that undercut professional claims
of expertise and privilege. It thereby reduced public confidence in
physicians and further weakened the social and poHtical position
of the profession. Fee-splitting could not resolve conflicting
interests between specialists and GPs at the national level.

Ultimately, the development of specialties and subspecialties
has indeed reduced overall competition within the medical pro-
fession. The ratio of primary care physicians has fallen from more
than 170 per 100,000 population in 1900 to less than sixty per
100,000 today. ^^ But the division of physician labor into special-
ties created intraprofessional problems, pitting general practi-
tioner against specialist. The decline in primary care physicians
has eased the problem somewhat, but it was still a serious split
in the ranks at the turn of the century and an obstacle to the
efforts of the scientifically oriented elite practitioners and medical
faculty who led the reform movement.

New levels of accreditation of specialists emerged in the
twentieth century. The American College of Surgeons was
charged with being elitist and un-American for its efforts to
restrict surgery to specially licensed physicians and to accredited
hospitals. In 1912 Franklin Martin's public relations tour for the
College of Surgeons was interrupted with heckhng by hostile
GPs. The college fellows were accused either of degrading the
profession by forming "a glorified surgical union, along labor
lines" or of estabUshing a new oligarchy, "an exclusive Four
Hundred in the profession. "^^

The reform leadership gathering in the wings of the AMA
included many leading specialists, but they saw the importance of
putting the interests of the profession as a whole at the forefront
of their campaign. After failing in 1898, they succeeded in 1901
and 1902 in their efforts to reorganize the AMA into a more
effective national organization. Their strategy included the
delicate issue of unifying the competing specialists and general
practitioners and bringing the specialists into the profession's
main political arm — the AMA.

GAINS AND LOSSES

Scientific medicine was clearly an effective doctrine for the
reform and uplift of the medical profession. It increased the

Scientific Medicine I I 95

technical effectiveness of doctors, providing a basis for increasing
public confidence in the profession. The need for research and
the teaching of medical sciences created a whole new category of
academic medicine. It united the interests of these academic
physicians, who sought total victory for scientific medical schools
over less adequate ones, with the interests of elite practitioners,
who wanted to reduce production of and competition among
doctors in order to raise their incomes and status. The require-
ments of scientific medical education strained the resources of
"commercial" medical education to the breaking point, closing
down many medical schools and reducing the production of
physicians. It also provided the rationale for requiring extensive
preliminary education of medical school applicants, forcing the
poorer classes out of medicine and thereby raising the social class
base of the profession. Furthermore, scientific medicine under-
mined sectarian medicine, uniting most of the divided profession
under the banner of "nonsectarian" scientific medicine. Finally, it
provided a basis for further decreasing competition within the
profession through the development of specialization. Thus,
scientific medicine helped complete the professionalization of
medicine.

These gains to the medical profession were accompanied by
some losses. Some of the losses were borne by less powerful
members of the profession. The gains of specialists, the new elite
among practitioners, were the losses of the general practitioners.
Scientific medicine provided the profession's scientific elite with
the means of securing its position and taking complete control.

While society benefited from more effective techniques
against infectious diseases, people lost the benefits of traditional
techniques and became dependent on technological medicine.
The propaganda of the reform-minded elite sold scientific medi-
cine as the last word on matters of health and disease. Through
their campaign, the medical profession excluded herbal methods
of prevention and therapy that are only now regaining popular-
ity. They also narrowed the scope of medical inquiry to reduc-
tionist concepts, all but ignoring the social and economic contexts
of health and disease.

The doctor was portrayed as omniscient and his skill as all-
powerful. Patients, accepting the profession's claims and want-
ing something for their money, began to expect their doctors

96 I Scientific Medicine I

to provide remedies for their suffering. Not wanting to discourage
this profitable attitude, most physicians beheved that, in the
words of a late nineteenth-century physician, "he fails of his duty
and his privilege who neglects to do something for the patient."*''
However, even this lucrative attribution of physician omniscience
was a double-edged sword. Armed with assurances of the near-
infallibility of medical science, patients demanded compensation
when they were maimed by the therapies or mistakes of scien-
tific doctors. The number of malpractice suits from 1900 to 1915
exceeded the number of suits during the entire nineteenth cen-
tury.**

Naturally, the most oppressed groups in society suffered the
most from the complete professionalization of medicine made
possible by scientific medicine. The poorer classes in general and
ethnic and racial minorities in particular have suffered doubly —
by being excluded from entering the profession and by losing
medical care that was indigenous to their communities and
accessible to them. By the early 1900s people who could afford
specialists increasingly relied on them, often by-passing the
general practitioner altogether. The poor filled the waiting rooms
and examining tables of teaching hospitals to become the teach-
ing and research material for interns, residents, and specialists.
The nation's wage earners, excluded from charity clinics by means
tests and often unable to afford private specialists' fees, became
the bread-and-butter clients of the nonelite general practitioners.*'
Following the largely successful doctors' campaigns to rid the
country of midwives, working-class and rural women and men
lost the services that helped maintain the integrity of their fami-
nes during the disruption of childbirth and found themselves hav-
ing to pay the higher fees of physicians and the cost of a hospital
bed.'° Women suffered from unnecessary surgery and suffocating
attention from gynecologists. They, like the working class and
racial minorities in general, were also excluded from becoming
doctors.

The fewer physicians competing for consumers' dollars, the
higher physicians' incomes rose and the fewer doctors who
practiced in working-class and poor sections of the cities and in
the countryside. The middle class became the main source of
income for the majority of the profession. As Morris Fishbein,
editor of the AMA Journal, complacently observed in 1927, "The

Scientific Medicine I I 97

physician of the future will deal largely with this group. From
them most of the physicians, who are themselves of the middle
class, will derive their incomes."^'

The dynamics that lifted white middle-class and upper-class
male physicians to the top of a hierarchy were not based on
conspiracies or conscious deceptions. Physicians acted in their
collective self-interest. While the different interest groups with-
in the profession often clashed, their conflicts were gradually
overwhelmed by the growing belief that all who embraced scien-
tific medicine would benefit. Old-time homeopaths and eclectics,
of course, fell by the wayside, and proprietors of crassly commer-
cial medical schools lost their lucrative businesses. But most
physicians could relate to the purposes of the reform campaign —
more respect for their skills, higher social status, more money —
and to the necessary means of achieving them. Undoubtedly con-
spiracies and conscious deceptions occured along the way (we will
see some examples in Chapter 4), but even the reform leaders
believed their mission would benefit society as well as the med-
ical profession. Nevertheless, it strains the imagination to con-
clude that the complete professionalization of medicine served
the interests of more than a small minority of the population.

The technical limitations of nineteenth-century medicine were
replaced by technical narrowness in the twentieth century; the
professional pluralism, by professional monopoly controlled by
elite specialists and medical academicians; the culturally diverse
and widely distributed group of healers, by a more fully stratified
and, for many, inaccessible professional class. These were some,
of society's losses that accompanied the profession's gains. The
consolidation of a scientific medical profession, however, also
provided important gains for the corporate class in America.

CHAPTER

Scientific Medicine II:
The Preservation of Capital

Scientific medicine, while providing well for the medical profes-
sion, also posed a major and unresolvable contradiction for
doctors. Medical science, as it developed in capitalist countries,
was built up around technology. The higher the level of technolo-
gy, it was believed, the more effective or, at least, salable were
the services of practitioners and researchers. But the higher the
level of technology, the more capital was required for medical
practice as well as for research. Investments in hospital and
laboratory facilities and tremendous expenses for highly special-
ized faculty and researchers were beyond the resources of
physicians themselves.^ Doctors had to turn outside the profes-
sion for capital, and in 1900 there was only one class who had
such money. Wealthy capitalists were in a position to dictate
terms to the profession — policies that served their own interests
as much as or even more than those of the profession itself. In this
chapter we will see how medical science opened the door to
capitalist intervention and the ways scientific medicine served not
only the needs of the medical profession but the interests of
capitalism as well.

MEDICAL TECHNOLOGY AND CAPITAL

The nineteenth-century family doctor owned a few instru-
ments— specula, a thermometer, and a stethoscope for examina-
tions, saws for amputations, a chest of medicines to be sold to

Scientific Medicine II I 99

their patients — a small investment indeed. But twentieth-century
medicine required greater technology than any single physician
could afford. Hospitals, once the institutions to which the poor
were taken to die, became the workshop for the doctor. Not
only did the hospital provide the doctor with fully equipped
operating rooms, x-ray machines, and other diagnostic and
therapeutic instruments. It also provided auxiliary personnel who
would isolate patients from their families, place them under the
control of technical experts, and insure that the doctor's orders
were carried out. Just as the buggy carrying the doctor to the
patient's house symbolized the nineteenth-century doctor-patient
relationship, the patient in the doctor's moderately equipped
office and then the doctor and patient in the hospital symbolized
the modernized counterparts.

Large-scale development of hospitals in the 1890s followed
the development of surgery as a specialized skill. The renowned
surgical skills of Halsted at Johns Hopkins and of others at the
Mayo Clinic provided popular support for the profession's pleas
that hospitals with modern surgical facilities be built. Rosemary
Stevens notes, "Most of the hospitals now in existence were
founded between 1880 and 1920, and the middle class for the first
time entered hospitals on a large scale." In 1873 there were only
178 hospitals in the United States. By 1909 there were 4,359
hospitals with a total bed capacity of 421,000.^

Physicians grew increasingly dependent on hospitals. By 1929,
seven out of ten physicians had some kind of hospital affiliation.
In New York and Chicago, the average physician, whether gen-
eralist or specialist, spent as much as 30 percent of his or her
time in hospitals and clinics.^ Even by the turn of the century the
medical profession was growing dependent on expensive, institu-
tionalized technology.

The capital needed for hospitals, medical education, and
research was beyond the means of the profession itself. A fully
equipped, medium-sized hospital was an expensive building
project. Then, too, room and service charges could not reasona-
bly be expected to pay for the annual costs of running the
hospital, especially when hospitals were free-of-charge work-
shops for the doctor. Patients could be expected to pay a certain
amount for their hospital care, but beyond a very vaguely
determined limit, any additional hospital charges would reduce

100 I Scientific Medicine II

utilization and cut into the revenues of both hospital and
physician. Thus, each year hospitals accumulated deficits that had
to be paid off.

Deficit financing reflected the social role of hospitals as
charitable institutions. Historically, from their development as
medieval refuges for the diseased poor to their more recent role
of providing for the sick of all classes, hospitals have consistently
reflected the class structure of the society. Fitting their position in
the class structure, the rich have been expected to pay the
complete costs of their own private space and attentive care. The
middle classes, with less commodious faciHties and fewer staff to
attend to their wants, have been expected to pay their own costs
but not necessarily to support all aspects of the hospital. The
poor, until recently, have been expected to pay in accord with
their means, and that has been very little. Their care has been
categorized as charity, and, consistent with widespread notions of
the importance of work and of the slothfulness of the poor, the
facilities and care provided for them have been austere at their
best and humihating at their worst. Furthermore, with the asso-
ciation of increasing numbers of hospitals with medical schools,
the poor have become the profession's research and teaching
material. To complete the differentiation of class relations re-
flected within the hospital as well as to balance the hospital's
books, the rich have been called upon to give money to the hospi-
tal to pay the costs of care given to the poor. The charitable
nature of hospitals gives wealthy people an almost perfect
opportunity to demonstrate their noblesse oblige within an
institution that publicly reflects and thus reinforces the class
structure of society.

The organization and financing of hospitals clearly provides
physicians with the facilities to practice their profession and make
money, and it benefits the upper-middle and upper classes by
providing them with facilities consistent with their social status
and opportunities to demonstrate their superior class positions
through charity to the hospital. The dependence of the medical
profession on the wealthy could create antagonism, but with their
compatible interests in the hospital, their relationship has been
symbiotic. Local wealthy men and women opened their hearts
and loosened their purse strings to hospital fund raisers.

Medical research and medical education were different issues.
Hospitals appealed to a local constituency whereas the new

Scientific Medicine II I 101

scientific medical schools drew their students and faculty from at
least the state and more often a whole region or even the nation.
Medical research was a long-term investment in developing new
knowledge and technology that would serve the country as a
whole rather than provide a subordinating service to the poor.
Medical faculty and researchers were no longer the local physi-
cians of distinction; their reputations were made nationally within
their own ranks, or not at all. Local rich men and women could be
cajoled into providing a laboratory at their nearby medical school
through appeals to local pride, but these objects of charity lacked
the drama of hospitals serving the poor and providing facihties for
physicians known throughout the local community. Medical edu-
cation and medical research involved much larger sums of money
than hospital construction, and the endowments to support fac-
ulty and researchers required still larger investments out of the
wealth of the local upper class.

The combination of the larger sums required, the less directly
charitable and less visible functions of medical research and
education, the long-term investments they represented, and the
more national character of their appeal made medical education
and medical research the philanthropic objects of a national
wealthy class more than of those whose wealth was local in its
character or size. By the 1890s a new national capitalist class
overshadowed the local business and aristocratic elites.'^ Their
wealth was derived from investments in national corporations,
and their visions of what was good and necessary for society were
broader than their local and lesser counterparts. Many of them
gave without strategy in their benefactions, except the courting of
good will, but some had strategies and interests of their own.

Just as well-connected local physicians appealed to the local
pride and charitable obligations of the local upper-middle class to
build a modern hospital for their community, so did academic
physicians and medical scientists turn to men and women of
broader wealth with appeals to the needs of society. A few
illustrious centers of medical education and research were rel-
atively well off. Charles Eliot clearly saw that the way to attract
large gifts and endowments was to reform Harvard's medical
school. Johns Hopkins willed a hospital and medical school as
well as a general university from his Baltimore and Ohio railroad
fortune; yet more was needed and gotten from wealthy individu-
als to open the medical school. These cases were the exceptions.

102 I Scientific Medicine II

"Not half a dozen institutions have received any considerable
sums, and very few anything at all," the AMA Journal com-
plained in 1900. The endowments necessary to "advancing med-
ical education and medical science" must come from outside the
profession.^ As some reform leaders foresaw and feared, there
was danger in dependence on philanthropy for that capital.

WELCH: A ROCKEFELLER MEDICINE MAN

William H. Welch's personal plight and eventual success are
indicative of the rising star of medical research. Returning in 1878
from his pathology studies in Germany, Welch found little
support in New York for devoting himself to laboratory research.
Although he received mild encouragement from Francis Dela-
field at the prestigious College of Physicians and Surgeons, he
could not find any space in which to set up a laboratory. Finally,
he turned to the lesser-rated Bellevue Hospital medical college
and negotiated the use of three rooms, some kitchen tables, and
twenty-five dollars in equipment. With frogs gathered from the
marshes of his sister's upstate New York home, Welch began the
first laboratory course in pathology given in an American medical
school. He got by with fees from his six students, a partnership
with another doctor preparing medical students for competitive
examinations, and assisting Dr. Austin Flint, a rich and socially
prominent professor of medical practice at Bellevue.^

Welch's European studies and original work brought him
immediate recognition. Within a year the alumni of the College
of Physicians and Surgeons contributed enough money to offer
Welch a modest pathology laboratory at their alma mater, but
Welch felt a commitment to Bellevue and also wanted to hold out
for the security and completeness of the chair in pathology at the
new Johns Hopkins medical school. Drawn by the "more
academic" environment at Hopkins, relief from "the drudgery of
teaching," an endowed $4,000 a year salary and paid assistants,
Welch shocked the New York medical profession and friends by
giving up a future income of "at least $20,000" for provincial
Baltimore.''

Welch took the position at Hopkins in 1884. Before going to
Baltimore, he spent most of a year studying bacteriology in
Leipzig and in Berlin with Koch. He studied bacteriology largely

Scientific Medicine II I 103

because he feared he would be left behind in the growing
competition for medical discoveries.^ Welch's singular devotion
to his career brought him success. Despite the adulation and
social popularity he received, he isolated himself from personal
intimacy with any other person, male or female.^

Welch's reputation as a researcher and organizer of research
grew even before the Johns Hopkins medical school opened its
doors in 1893 with Welch as its first dean. By the turn of the
century, Welch's professional reputation began spilling over into
lay circles. In 1901 he came to the attention of Frederick T.
Gates, the grand master of the Rockefeller philanthropies. Welch
was asked to help organize the Rockefeller Institute for Medical
Research. He soon became chief adviser to the Rockefeller
foundations on medical projects, assisting in important ways in
funding medical education in the United States and China, in
developing public health programs in the United States and
around the world, in organizing and heading this country's first
school of public health, and more. In 1930 his eightieth birthday
was honored around the world with a live radio broadcast
throughout the United States and Europe presided over by
President Hoover and simultaneous celebrations in major cities in
Europe and Japan.

William H. Welch was indeed a man whose life and career
spanned the fortunes of medical science, from its struggling
infancy to its prodigious material success. His life combined the
perfect mix of ambition, talent, single-minded dedication, and
opportunity to make him the ideal of academic medicine in the
United States. His gregariousness and wit kept him from being
the recluse that his rejection of intimate relationships might have
otherwise encouraged. His considerable talent combined with his
initially almost frantic ambition to give him a competitive edge in
medicine.

Nevertheless, these qualities would have yielded few rewards
had the opportunities not come at the right moments. If Welch
had not been born a white male into a prosperous class, he would
never have had the material support he needed. If Welch had
been born fifty years earlier, there would have been no support
for scientific medicine. If he had been born fifty years later, he
might well have been just another competent medical researcher.
If Johns Hopkins medical school had not been filling its faculty

104 I Scientific Medicine II

slots when he was an ascending star in New York medical science,
he might have been forced to divert energy into a lucrative
private practice and lost his singular immersion in medical
academia. If the Rockefeller philanthropies had not sought to
develop scientific medical research, to reform medical education,
and to develop public health programs, he might not have had a
sufficient vehicle for his talents and might not have achieved his
reputation as a world statesman and celebrity. While Welch was
the right person in the right place at the right time, his spectacular
career depended upon more than luck. His sex, race, and social
class were crucial conditions for his success. But the development
of corporate capitalism was perhaps the most important condition
because it provided the ideological and cultural support for
scientific medicine and the material support for his research.

It is likely that Welch would have fared well even without the
Rockefellers since his reputation would have enabled him to skim
off the best positions in medical science. Medical research and
education as a whole, however, were helped immensely by the
wealth of the Rockefeller fortune. Under the skillful direction of
foundation officers, the Rockefeller wealth became the largest
single source of capital for the development of medical science in
the United States, the conversion of medical education to a
scientific research basis, and the development of public health
programs in the United States and abroad.

For the first quarter of the twentieth century the Rockefeller
officers developed a definite strategy for their capital investment
in medicine. That strategy sometimes supported and often
opposed different interests in medicine, but such alliances and
conflicts were never accidents on the part of the foundation. They
were anticipated and necessary consequences of the role of
modern medicine in the society, as desired and articulated from
the very pinnacles of the American class structure.

Why was so much Rockefeller money — $65 million by 1928 —
lavished on a single institution devoted to scientific medical
research? What motivated the men at the Rockefeller philanthro-
py to spend so much of their energy and money on medicine?
How important were their humanitarian feelings for their fellow
human beings? Did they envision material benefits from their
work? As capitalists and corporate managers, did they beheve it
would further their personal interests or their class interests? The

Scientific Medicine II I 105

self-consciousness of their pioneering effort made accessible the
concerns and thinking behind the facades constructed in foun-
dation-funded histories and authorized biographies.

ROCKEFELLER MONEY AND MEDICAL SCIENCE:
A SOCIAL INVESTMENT

On June 2, 1901, New York's newspapers hailed the founding
of the Rockefeller Institute for Medical Research. The most
celebrated example of private philanthropy supporting medical
research, the institute began a new epoch in the United States.
More than its predecessors abroad, the Rockefeller Institute
would attack a broad range of diseases, seeking understandings of
their biological and chemical causes, developing methods of
prevention and cure, and training hundreds of researchers for
medical science.

The institute began modestly with a commitment of $20,000 a
year for research grants and soon after an outright gift of $1
million from John Davison Rockefeller. By 1928 Rockefeller gifts
to the institute totaled $65 million, an enormous sum for the
period. Although the elder Rockefeller and his son are most
widely known for the benefactions, it was Frederick T. Gates who
formulated the strategies and initiated the investments in medical
research, medical education, and public health.

In 1915 Gates set down his memories of the origins of the
institute. His anecdotal recollection stands as the widely quoted
history of the origins of Rockefeller medical philanthropy. '° As
folklore, it conveys the process and motivations the creator of the
Rockefeller Institute wished us to believe about the germination
of his interest.

In his retrospective story, Gates describes how the idea for the
institute came to him. As minister of the Central Baptist church
in Minneapolis from 1880 to 1888, Gates had countless experienc-
es with regular and homeopathic doctors. His visits to "hundreds
of sick rooms" and his close relations with several physicians
confirmed "a profound scepticism about medicine of both schools
as it was currently practiced." As for homeopathic medicine, he
concluded that Samuel Hahnemann, the founder, was "Httle less
than a lunatic." He had little more confidence in the regular, or
orthodox, school.

106 I Scientific Medicine II

Then in 1897, six years after joining Rockefeller's staff, he
befriended a former member of his Minneapolis congregation
who was a medical student in New York. He asked the young
man to suggest a readable medical text used in the best medical
schools. On his young friend's recommendation, Gates bought
himself a copy of William Osier's Principles and Practice of
Medicine, first published in 1892, and a pocket medical dictio-
nary.

Gates took Osier's book with him to join his family vacation-
ing in the Catskills and read through its approximately 1,000
pages of revelations about the state of medicine. Osier laid bare
the limitations of current medical knowledge and practice. Gates
learned that many diseases were caused by germs, only a very few
of which had been identified and isolated but many of which "we
might reasonably hope to discover."

When I laid down this book, I had begun to realize how woefully
neglected in all civilized countries and perhaps most of all in this
country, had been the scientific study of medicine. I saw very clearly
also why this was true. In the first place, the instruments for
investigation, the microscope, the science of chemistry, had not
until recently been developed. Pasteur's germ theory of disease was
ver> recent. Moreover, while other departments of science, astrono-
my, chemistr>% physics, etc., had been endowed very generously in
colleges and universities throughout the whole civilized world,
medicine, owing to the peculiar commercial organization of medical
colleges, had rarely if ever, been anwhere endowed, and research
and instruction alike had been left to shift for itself dependent
altogether on such chance as the active practitioner might steal from
his practice. It became clear to me that medicine could hardly hope
to become a science until medicine should be endowed and qualified
men could give themselves to uninterrupted study and investigation,
on ample salary, entirely independent of practice. To this end, it
seemed to me an Institute of medical research ought to be
established in the United States.

In July, Gates returned to his office in the Standard Oil
building with "my Osier" in hand and dictated a memorandum to
Rockefeller. He laid out his conclusions about the tragic state of
medicine in the United States and its immense potential. He
pointed out the usefulness of the Koch Institute in Berlin and the
Pasteur Institute in Paris. In support of his recommendation for

Scientific Medicine II I 107

an American institute, Gates explained to Rockefeller that
Pasteur's discoveries about anthrax and diseases of fermentation
"had saved for the French nation a sum in excess of the entire
cost of the Franco-German War." He also insisted that an
institute founded by Rockefeller would encourage other wealthy
men and women to found and endow other research centers, with
the total effort yielding "abundant rewards."

While the memo to Rockefeller did not result in immediate
action, it did provide the coherent rationale six months later for
opposing the affihation of Rush medical college with the Univer-
sity of Chicago, at the time Rockefeller's dearest and largest
philanthropy. Rush was a respected school of the regular
profession, a follower of the scientific vanguard but not among
them. Gates got Rockefeller's support for a letter urging the
university's administrators to abandon Rush and offering them
instead a new medical center, "magnificently endowed, devoted
primarily to investigation, making practice itself an incident of
investigation. " For some reason, probably related to the influence
in Chicago of Rush's wealthy and socially and politically promi-
nent practitioner- faculty members, the marriage was consummat-
ed anyway. Chicago lost its chance for the proposed institute.
Thus was Gates' idea for the institute born and preserved from
the clutches of medical sectarianism.

Gates' proposal was carefully considered through 1899 and
1900. Gates and Rockefeller, Jr., who joined the philanthropy
staff in 1897, hired Starr J. Murphy, a lawyer friend and
Montclair, N.J., neighbor of Gates, to study European institutes
and confer with leading medical researchers in this country. L.
Emmett Holt, pediatrician to several of Senior's grandchildren
and a fellow parishioner at Junior's Fifth Avenue Baptist church
in New York, impressed upon Junior the broad and basic
biological research that led to the recent discovery of diphtheria
antitoxin. What was needed to solve other great problems in
medicine, he told the younger Rockefeller, "were men and
resources which could be devoted solely to the work of re-
search."^^

Finally, in December 1900 John Rockefeller McCormick, the
elder R.ockefeller's three-year-old grandson, fell ill with scarlet
fever. On the second day of the New Year he died. Any hesitancy
the old man, a follower of homeopathy, felt about endowing

108 I Scientific Medicine II

scientific medical research was undermined when he was told by
respected New York doctors that they knew Uttle about the cause
of scarlet fever and had no cure for it.^^

Gates and the Rockefellers were also concerned about com-
petition for their proposed institute. Andrew Carnegie's rival
research institute, endowed with $10 million as the Carnegie In-
stitution of Washington in 1902, was then in the planning stages.
Rockefeller, Jr., was sufficiently concerned about the competi-
tion to wring an agreement from the steel king that his institu-
tion would not enter the field of medical research. At the same
time Henry Phipps was founding an institute for the study of
tuberculosis in Philadelphia. Competition struck close to home
when Rockefeller's daughter Edith and son-in-law Harold F.
McCormick unveiled their plans for a tribute to their son, the
John Rockefeller McCormick Memorial Institute for Infectious
Diseases in Chicago. ^^

By March 1901 Rockefeller committed himself to funding
Gates' proposed institute. The Rockefeller Institute for Medical
Research began its work with $20,000 a year for grants to medical
researchers and soon thereafter a $1 million gift from Rockefel-
ler, a board of directors composed of physicians — including Holt
and Welch — with training in pathology and a commitment to
bacteriological research, and Dr. Simon Flexner as the executive
director.

For more than two years Gates grew increasingly impatient as
the "medical gentlemen" restricted themselves to supporting
small research projects around the country. ^"^ Finally, in the fall of
1904, the board opened its first laboratories and began its own
program of medical research. In November 1907 Rockefeller
gave the institute an additional endowment but held back half the
$6 million requested by the directors. Finally, in October 1910,
after the institute was reorganized — reducing the board of di-
rectors to a lesser role as the Board of Scientific Directors and
creating a new board of trustees with Gates as chairman —
Rockefeller added to the institute's endowment, providing it with
the yearly income from $6.4 million of investments. By 1920 the
Rockefellers had given the institute $23 million and by 1928 some
$65 million.^'

The institute was organized independently of any university
primarily for reasons of efficiency and to avoid conflict with

Scientific Medicine II I 109

Senior's commitment to homeopathy. First, Gates and Rockefel-
ler, Jr., wanted the institute free of any teaching pressures. The
objective of the institute was to produce results in medicine in
order to reduce the amount of disease in society, and it would be
a diversion of resources to ask the researchers to teach. '^

Second, the handful of scientific medical schools, while nom-
inally above medical sectarianism, were the turf of the regular
profession's elite. The elder Rockefeller, a lifelong follower of
homeopathy, objected to any move that strengthened the regular
profession in its conflict with homeopathists. It was undoubt-
edly on this basis that Rockefeller in 1898 supported Gates' ob-
jection to the alliance between the University of Chicago and
Rush Medical College, a creature of the regular profession and
an opponent of homeopathy. Columbia and Harvard were
briefly considered as recipients of the institute, but they were
elite regular medical schools. Although neither Gates nor Junior
took the old man's concerns seriously, they had to avoid pro-
voking his objections that they were merely supporting one side,
the wrong side in the conflict. With the example of the inde-
pendent Pasteur Institute before them, the efficiency of a purely
research institute as their primary concern, and their desire
to assuage Senior's hostihty to regular schools. Gates and Rocke-
feller, Jr., agreed to exclude any university affiUation for their
project. ^^

HOMEOPATHY: THE CONFLICT SIMMERS

The conflict over homeopathy continued for some years. It
is an illuminating example of the workings of the Rockefeller
philanthropies, and it suggests an ideological difference between
the robber barons like Senior who built up huge industrial
empires and the next generation of corporate capitalists who ran
the operations.

Rockefeller continued to express his concerns that within the
institute and later in his philanthropies' support for medical
education, his money was being used to support the regular
profession at the expense of the homeopaths. "I am a homeopath-
ist," he scolded his staff in 1916. "I desire that homeopathists
should have fair, courteous, and liberal treatment extended to
them from all medical institutions to which we contribute."^* In

no I Scientific Medicine II

1919, when he was considering a $45 milHon gift to his General
Education Board to support medical education, Rockefeller
again warned his son and staff: "Homeopathic teaching should
not be excluded ... it should be provided for, the same as
Allopathic. "•^*

His son and his staff firmly and repeatedly explained that
"scientific medicine has rendered obsolete the former distinctions
between the so-called Homeopathic and the so-called regular or
Allopathic schools. "^'^ The new medicine is free of dogma, free of
values. It represents not "preconceived notions" about the world
but only "ascertained facts. "^^ Medical science is devoid of "med-
ical dogma of any kind."^^

Furthermore, as the homeopaths and regular schools "are
constantly drawing nearer together," a trusted adviser wrote the
old man, "the discriminations which formerly were practised
against homeopathists are being constantly lessened." Simon
Flexner provided assurances that at the Rockefeller Institute
"they make no distinction and welcome to their staff qualified
men irrespective of the school in which they have been trained. "^^

That John D. Rockefeller personally patronized a homeopath-
ist might seem surprising. However, Rockefeller and homeopathy
were both products of the nineteenth century. From the mid-
nineteenth century on, homeopathy in the United States ap-
pealed primarily to the upper classes. It was safer than the heroics
of regular medicine, and it was a sign of affluence and taste since
it was very fashionable among the European nobility and upper
class, who were aped in many ways by wealthy Americans. ^"^
Rockefeller, who was twenty-two at the outbreak of the Civil
War, grew up believing that homeopathy was medically and
socially desirable.

Furthermore, while Rockefeller used chemists and engineers
in developing his Standard Oil empire, his chief assets were
an unbridled ambition and an intuitive and cunning sense of
opportunity and organization. He accumulated the largest for-
tune among all the robber barons by paying his workers as little as
possible and by ruthless methods in the marketplace, extracting
huge rebates from the railroads for his shipments and cutting the

*"Allopathic" was another term for the regular, or orthodox, sect of the medical
profession.

Scientific Medicine II I 111

price of refined oil products to drive his competitors out of
business. He did not fully share his son's and his later managers'
appreciation of the importance of science in developing the base
of industrial capitalism.

In his retirement and devotion to giving away his fortune,
Rockefeller generally gave free reign to Gates and his son. He
knew that his caution in disposing of his fortune was shared by his
trusted lieutenants. Within his philanthropies he had the money
but did not take the authority to establish policy. It seemed
sufficient to him that his name was no longer the object of spittle,
but rather gratitude. Except for occasional questions, taciturn
consideration of his advisers' requests for millions of dollars, and
objections to the treatment of homeopathists, Rockefeller, Sr.,
left the running of his philanthropies and his financial empire
alike to Gates and his son.

Although Gates and Junior worked together in developing
programs and prying gifts from the occasionally reluctant father.
Junior himself acknowledged that "Gates was the brilliant
dreamer and creator," and "I was the salesman, the go-between
with father at the opportune moment. "^^ Fortunately for history.
Gates was a prolific writer of his ideas, leaving his thoughts in
letters to Rockefeller, Sr., speeches to the various philanthropic
boards, and memos to himself and his staff. Given his central role
in the Rockefeller philanthropies and the importance of these
philanthropies in the development of scientific medicine, it is
illuminating to consider Gates' views of the role and consequenc-
es of medical science.

SCIENTIFIC MEDICINE AND CAPITALIST GATES

Gates, the premier Rockefeller medicine man, was attracted
to medical science. It was not the appeals from medical science
that drew his interest or his money. He was, like most educated
people of the late nineteenth century, vaguely aware of the march
of progress in medicine. He knew of Pasteur and the germ theory
of disease. He had read Osier and understood the potential of
medical science. But he never heard of Dr. Simon Flexner or Dr.
William H. Welch, and he had no contact with other medical
scientists until he initiated the medical institute. Nevertheless, he
did "intelligently and clearly see that there was a tremendous

112 I Scientific Medicine 11

need of medical research." Whatever requests for money for
medical science crossed Gates' desk, none was taken seriously
until 1907, when McGill University asked for aid to replace two
medical school buildings that had been destroyed by fire.^^

Gates was always an autonomous figure in medical philan-
thropy. He was moved by his own conceptions of the value of
medicine and his own strategies for developing its role in
American society. He was certainly influenced by medical men
whom he respected, above all Simon Flexner and William Welch,
but it was because their ideas and contributions conformed to his
plans for the transformation of medicine. What visions did he
have of the role and functions of scientific medicine?

We may grant that Gates had genuinely humanitarian motiva-
tions. His ministrations to the sick and dying in his Minneapolis
parish undoubtedly evoked sympathy for their suffering. In his
later years he credited medical science with standing above all
other elements of history. None but medicine has "done so much
to promote all the forces of civilization, to increase human
happiness or to ameliorate human suffering."^''

Typical of Gates, his enumeration of the accomplishments of
medical science places the relief of human misery after the
promotion of the "forces of civilization." This is not a petty
criticism, for Gates' preeminent consideration was the develop-
ment and extension of Anglo-American civilization. What he
understood that civilization to represent will become clear in the
following pages, but in its essence "civilization" meant the values
of work and disciplined living, a social life organized around
productive labor and frugal consumption. "Civilization" also
meant the right and indeed the responsibility of men of wealth to
govern society and of industrial societies to direct economically
less developed societies. In brief, "civilization" was equated in
Gates' mind with industrial capitalism and imperialism.

What value did scientific medicine have for capitalism? Gates
envisioned numerous material and social-political consequences
flowing from medical science in a never-ending stream of support
for capitalist society.

HEALTHIER WORKERS

The material benefit of medicine is a healthier population and
thus a healthier work force. What Pasteur's work on anthrax had

Scientific Medicine II I 113

done for the French cattle industry, medical science could do for
the whole society. The findings of medical science were most
important when applied to preventing disease. "By keeping
well," Gates observed, a person "enjoys all the employments,
pleasures, and financial gains of continuous health." Gates
insisted from the beginning of his career to its end that "the
fundamental aim of medical science ought to be not primarily the
cure but primarily the prevention of disease."^*

Gates believed that events supported his contention. In the
first quarter of the twentieth century, "sanitary science and
preventive medicine" had reduced sickness by half, he asserted,
citing support from U.S. Census Bureau reports of mortahty
rates, insurance company statistics, and reports of state and local
health boards. ^^ Although sickness was still a major obstacle to
the full utilization of labor, the assault by the forces of science
was paying off. Gates cited a report that 20 percent of the
employees of large companies were home sick each day, but, he
added, triumphantly, "I think that even so high a figure is far
below that of the armies of [General] Washington. "^°

Gates was far from a solitary figure preaching the potential of
medicine for capitalists. Big business. Gates observed in 1925,
sponsored preventive medical care programs on a large scale
"because health is found in a variety of ways to be profitable."^'
Healthy workers are profitable because they are an employer's
"human capital" to be utilized for production of salable goods
and services. Just as the capital invested in machines needs to be
protected by adequate maintenance programs, so too does
human capital require maintenance and repair, a perspective long
recognized in many contexts.

Southern slave owners and their physicians viewed their black
slaves as a capital investment to be saved from disability or death
whenever possible, lending credibility to the myth of paternalistic
slavery. In a study of the role of medicine in the ante-bellum
South, Walter Fisher concluded that the primary reason why
slaves were provided with medical care was the tremendous
economic investment they represented to slave owners. ^^ Every
planter understood that "to save his capital was to save his
negroes," observed Dr. Richard Arnold, an upper-class physician
in Savannah. The self-interest of the slave-owning class in the
preservation of its investment made Southern slavery "the only

114 I Scientific Medicine II

institution in which Interests and Humanity go hand in hand
together," Dr. Arnold wryly added."

It was not only racism and slavery that facilitated "paternalis-
tic" self-interest. The U.S. Sanitary Commission, organized in
1861 to provide medical relief to Union soldiers on Southern
battlefields, was by its own account no humanitarian enterprise.
Run by wealthy Easterners, the commission declared "its ulti-
mate end is neither humanity nor charity. It is to economize for
the National service the life and strength of the National soldier."
Saving a soldier's life, the commission calculated, reduced the
monetary cost of the war and preserved the soldier as a "pro-
ducer" when he "returned to the industrial pursuits of civil life."
Each soldier's life was worth "no less than one thousand dollars"
to society. ^"^

With the rapid development of an industrial base in the
United States during and after the Civil War, employers in many
industries viewed their workers as disposable resources. Particu-
larly with increasing mechanization in industrial production, a
decreased demand for skilled workers, and an unlimited supply of
desperate immigrants, the work force became a sea of men and
women to be plucked up by employers as needed and later tossed
out. Workers who were maimed, killed, or simply worn out by
their jobs were replaced by other bodies from among the
unemployed.

As the unemployed work force shrank with the outbreak of
war or upswings in the economy, as labor organized to change its
working conditions and pay, and as employers found that lost
production because of illness and rapid turnover of their workers
cost them profits, enhghtened businessmen developed new atti-
tudes toward their workers. It was not concern for the workers'
needs that led to better conditions and health and welfare pro-
grams. Rather these reforms sprang from the industrial unionism
and political organization of workers and from the opposing
necessity of employers to discipline the work force to the re-
quirements of capitalist production. The firm that improved its
working conditions reduced work days lost to strikes. The firm
that took pains to keep its workers found increased productivity
from its capital investment. The firm that offered company
housing, shares of stock, and company medical care increased the
dependence of the workers on the company and lessened the

Scientific Medicine II I 115

threat of unionization. And, in the early years of this century up
to World War I, industries that voluntarily acted could reduce the
risk of restrictive legislation demanded by the forces of Progres-
sivism. As early as 1892, following the bloody Homestead strike,
Andrew Carnegie articulated a more conciliatory policy toward
his workers to prevent the loss of experienced workers, though
there is little evidence that he or his company followed the policy.
"It is impossible," he said, "to get new men to run successfully
the complicated machinery of a modern steel plant."" Labor
stability became an important element in the productivity and
profit strategies of modern industries. "It is good business to
conserve life and health," observed John Topping of Republic
Steel, for thereby "one of the most important items of economy
in production is secured. "^^

Industrialists who weathered the marketplace and emerged
among the monopolistic leaders of their industry had the capital
and foresight to ward off unionization and stabilize their work
forces with health and welfare programs. Steel companies,
railroads, oil companies, and others created complete medical
care systems for their workers, hiring or contracting with
physicians and providing dispensaries or hospitals.

The efforts of slave owners and the U.S. Sanitary Commission
to preserve lives by curing disease were aimed at conserving
human capital, the one "belonging" to an individual and the
other profiting a whole class. The medical programs of individual
corporations were aimed more at undermining unionization and
stabiHzing their own work forces, with improved health an added
benefit rather than the main purpose. Thus, slave owners and
industrial corporations exhibited enlightened self-interest while
the upper-class sanitary commissioners demonstrated a more
far-sighted plan for investing in the whole society's work force.
The latter is an articulated interest of an entire class — the interest
of the capitaUst class in a stable and healthy work force.

Frederick T. Gates consistently articulated this larger per-
spective and shaped his philanthropic programs around it. He
understood the importance of a healthy work force to the growth
of capital and industrial output. The Rockefeller Sanitary Com-
mission, organized by Gates in 1909, sought to eradicate hook-
worm disease from the southern U.S. population. Charles
Warden Stiles, a government zoologist, convinced Gates and

116 I Scientific Medicine II

Junior that the hookworm was "one of the most important
diseases of the South" and a cause of "some of the proverbial
laziness of the poorer classes of the white population." Whatever
genuine pride the Rockefellers and Gates felt in relieving the
suffering of thousands of Southerners, their primary incentive
was clearly the increased productivity of workers freed of the
endemic parasite. Gates observed that the stocks of cotton mills
located in the heavily infected tidewater counties of North
Carolina were worth less than mills in other counties of the state
where fewer people were infected. "This is due," he explained to
Rockefeller, Sr., "to the inefficiency of labor in these cotton
mills, and the inefficiency in the labor is due to the infection by
the hookworm which weakens the operatives." Gates calculated,
"It takes, by actual count, about 25 percent more laborers to
secure the same results in the counties where the infection is
heavier." It also took 25 percent more houses for the workers,
more machinery, and thus more capital and higher operating
costs. "This is why the stocks of such mills are lower and the
profits lighter."^'

The Rockefellers did not have any significant investment in
Southern textile mills. Rather their extensive and widespread
investments gave them a concern for the productivity of the entire
economy. The Sanitary Commission was a logical extension of
their educational programs in the South (discussed in Chapter 1),
all directed ultimately to integrating the Southern economy into
the national dominion of Northern capitalists.

Through the International Health Commission — the first
program of the Rockefeller Foundation established in 1913 — the
hookworm and other public health programs were extended
worldwide. None of these programs was intended to prop up
specific Rockefeller investments abroad. They were directed
more generally at improving the health of each country's work
force to facilitate sufficient economic development to provide the
United States with needed raw materials and an adequate market
for this country's manufactured goods. Stacy May, an economist
and a director of a Rockefeller-controlled international invest-
ment corporation, recently reaffirmed the value of such pro-
grams. "Where mass diseases are brought under control, produc-
tivity tends to increase — through increasing the percentage of
adult workers as a proportion of the total population, [and]

Scientific Medicine II I 117

through augmenting their strength and ambition to work," he
observed.^*

Each of these programs can be traced to Gates' and the
Rockefellers' broader concern for the permanent economic and
social viability of capitalist society. Gates viewed the public
health in a larger capitalist class perspective than probably any
other important figure in the various medical reform movements
of the period. Although his articulated views on the relation
between health and capitalism were more complete than other
capitalists of his era, he was not alone in maintaining the
importance of such programs.

The American Association for Labor Legislation, a Progres-
sive era alliance of corporate-liberal business leaders, some labor
leaders, and upper middle-class reformers, won business support
for its proposal for compulsory national health insurance mainly
on the basis of the self-interest of employers. "Illness as well as
injury occasion a large economic waste to the company as well as
to the employees on account of lost time, idle machinery, and
ineffective work," reported Howell Cheney of the Cheney
Brothers' Silk Mills. "It is to the direct interest of the company as
well as to the individual to bring about a reestablishment of
health, and consequently efficiency, by supplying the best con-
ditions possible for recovery. "^^

The National Association of Manufacturers committee on
industrial betterment supported compulsory sickness insurance
against voluntary systems largely because of the importance they
attached to a healthy work force. "We know that there are
employers who would not comply with the voluntary plan," the
NAM committee warned. Even a corporation president who sees
the long-run advantages of "enhghtened" industrial relations may
bow blindly to maximizing this year's profits. This was an
important enough issue, they argued, that the State must
"subordinate the independence of the individual to the general
good.'"*^

It was not primarily a concern for conserving human life that
led America's corporate liberals in the Progressive era to support
compulsory health insurance. From Bismarck to the Conservative
party in England to the American Association for Labor Legisla-
tion and the National Civic Federation, the far-sighted leaders of
corporate capitalism believed that government-sponsored sick-

118 I Scientific Medicine II

ness insurance, workers' compensation, and other social security
measures would reduce the appeal of radical labor and socialist
movements/^ Hoping to depoliticize workers' unhappiness with
their lot, corporate leaders joined reformers in calling for such
moderate reforms. Despite this expedient application of medical
care programs, leaders of many corporations as well as the
conservative National Association of Manufacturers believed that
medical care, when extended to the whole population, would
substantially improve the health of workers and their families,
which included future workers.

Sharing the concern of the business class, the vanguard of
scientific medicine considered the economic benefits of medicine
among its most important effects. The smaller view pervaded the
thinking of physicians working in a particular company's health
programs. C. W. Hopkins, chief surgeon for the Chicago and
Northwestern Railway, told the 1915 annual meeting of the
American Academy of Medicine that the railroads found it
economically desirable to organize medical care programs be-
cause it cost them $500 to train an employee and because
experienced and healthy workers were important in reducing
accidents that injure passengers and destroy property. "It is now
a well-recognized fact among the managements of the railroads,"
reported Dr. Hopkins, "that it is just as important to care for
their sick and injured [workers] as it is to maintain a certain
standard of efficiency or perfection of their rolling stock and road
bed."^^

Broader views of medicine's material importance to society
guided strategies of men who led the medical reform movement
at elite universities and the national level. Charles W. Eliot, the
Harvard president who launched major medical reforms begin-
ning in 1869, considered medical research both pure and appHed.
At the dedication ceremonies for the Rockefeller Institute's
laboratories in 1906, Eliot characterized research medicine's
primary object as striving for "truth in the abstract" and its
secondary objects as preventing "industrial losses due to sickness
and untimely death among men and domestic animals," and
lessening the negative impact of sickness on human happiness. "^^

William H. Welch, at the same ceremony, asserted with pride
that scientific medicine made possible the "great industrial

Scientific Medicine II I 1 19

activities of modern times, efforts to colonize and to reclaim for
civilization vast tropical regions, [and] the immense undertaking
to construct the Panama Canal/"''' For the most part, academic
doctors were content to support the uses of medical science laid
down by the philanthropic strategists whose funding programs
guided the development and utilization of research. The medical
profession thus accepted the capitalist definition of health as the
capacity to work.

IDEOLOGICAL MEDICINE

AN INDUSTRIALIST WORLD VIEW

For philanthropist and capitalist Gates, the material conse-
quences of medical science were only one of its advantages.
Indeed, Gates gave more attention to the other advantages that
intrigued him. Probably more than any of his contemporaries,
Gates perceived and understood the ideological functions of
medicine. Some of his thoughts were implicit understandings of
the relation between scientific medicine and industrial capitalist
ideology. His most systematic thinking concerned the social value
of medical science as ideology and as a cultural force.

Members of any society or social class whose existence is
intimately tied to industrialism will find scientific medicine's
explanations of health and disease more appealing than mystical
belief systems. The precise analysis of the human body into its
component parts is analogous to the industrial organization of
production. From the perspective of an industrialist, scientific
medicine seems to offer the limitless potential for effectiveness
that science and technology provide in manufacturing and social
organization. Just as industry depends upon science for technical-
ly powerful industrial tools, science-based medicine and its
mechanistic concepts of the body and disease should yield
powerful tools with which to identify, eliminate, and prevent
agents of disease and to correct malfunctions of the body.

Gates and other industrial capitalists found a close correspon-
dence between this new medicine's concepts of the body and
disease and their own world view. The body, Gates believed, is a
microcosm of society, and disease is an invasion of external

120 I Scientific Medicine II

elements. Medical research must discover the agents of disease
and find the means of preventing their destruction of the body or
provide a cure. Health, in Gates' view, is the absence of disease.
"Nearly all disease," Gates explained to Rockefeller, "^^

is caused by living germs, animal and vegetable, which finding
lodgement in the human body, under favorable conditions multiply
with enormous rapidity until they interfere with the functions of the
organs which they attack and either they or their products poison
the fountains of life.

Nature's healing methods are strikingly similar to the organi-
zation of industrial society.

When, for illustration, the skin is cut with a knife, nature at once
begins to hurry to the point of disaster squadrons of white corpuscles
of the blood and other healing forces. Just as the fire engines start
from all quarters on the dead run to a fire when the alarm is
sounded, healing forces rush from every part of the body to the
point of trouble, some to destroy any poisonous germs that may get
into the wound, others to unite the wounded parts as before.

The body in which nature works is constructed like a
Lilliputian community, complete with modern social organization
and industrial plants.

The body has a network of insulated nerves, like telephone wires,
which transmit instantaneous alarms at every point of danger. The
body is furnished with a most elaborate police system, with
hundreds of police stations to which the criminal elements are
carried by the police and jailed. . . . The body has a most complete
and elaborate sewer system.

The body's industrial life exists in

an infinite number of microscopic cells. Each one of these cells is a
small chemical laboratory, into which its own appropriate raw
material is constantly being introduced, the processes of chemical
separation and combination are constantly taking place automatical-
ly, and its own appropriate finished product is constantly being
thrown off, that finished product being necessary for the life and
health of the body. Not only is this so, but the great organs of the
body like the liver, stomach, pancreas, kidneys, gall bladder, are
great local manufacturing centers, formed of groups of cells in
infinite number, manufacturing the same sorts of products, just as
industries of the same kind are often grouped in specific districts.

Scientific Medicine II I 121

"We are fearfully and wonderfully made," Gates ironically
concludes, as though praising some new machine created in
God's own image. Because "nature is the great physician," her
healing powers have obscured the failing of all pre- and nonscien-
tific forms of medicine. Recovery from disease before the advent
of scientific medicine, Gates believed, was due entirely to the
power of nature as healer. Homeopathic and orthodox medical
sects, Christian Science, psychic healers, osteopaths, Indian herb
doctors, and patent medicine men all survived by claiming
nature's cures as their own.

Only science was able to comprehend nature. "Science has
discovered the laboratories where she has stored her reserves and
has robbed her of them for use on human beings." Medical
researchers in Gates' day were pressing the campaign against
disease on two fronts: "they are trying to break into and expose
to the Hght many more of the secret processes in nature's
laboratories," and "they are working to create new chemical
combinations that will cure."

Gates thus appreciated the human body as one of nature's
puzzles, to be investigated and understood by science. His view,
shared by scientific doctors, engineers, professionals of all sorts,
and most corporate executives and owners, envisioned health as
the absence of disease and medicine as an engineering task.
Science was helping industry reshape the organization of produc-
tion by developing machinery to control and cheapen human
labor and more cheaply extract from nature a salable product.
Science would also extract from nature the secrets of life itself
while medicine would apply them to understand disease and
develop methods of preventing or curing these pestilences of life
and commerce. Improving the health of the population was thus
an engineering job that involved understanding and manipulating
nature.

Gates' views were not very different from those generally held
by medical scientists of his day. While few directly applied the
analogy of industrial society, nearly all conceived the body in
mechanistic terms that made such an analogy seem natural. The
similarity between the constructs of scientific medicine and the
world view of industrial capitalism made it seem natural for the
new order to support scientific doctors against all "quacks." The
medical profession benefited from the compatibility of its theo-

122 I Scientific Medicine II

ries with the perspectives of the newly dominant class, but the
capitalist social order won extraordinary ideological and cultural
advantages.

INDUSTRIAL CULTURE AND CAPITALIST LEGITIMATION

Scientific medicine's singular concern with the microbiological
interaction of the human body and specific disease states had
political consequences which Gates and a few others envisioned.
In brief, Gates embraced scientific medicine as a force that
would: (1) help unify and integrate the emerging industrial
society with technical values and culture, and (2) legitimize
capitalism by diverting attention from structural and other
environmental causes of disease.

Gates and other officers in the Rockefeller foundations
believed that medicine had an important cultural role to play.
Gates believed that the goal of medicine, the "healing ministra-
tion," is "the most intimate, the most precious, the superlative
interest of every man that lives." After food, water, sleep, and
sex, freedom from disease is the great longing of all peoples. The
desire for health is a unifying force "whose values go to the palace
of the rich and the hovel of the poor." Medicine is "a work which
penetrates everywhere." Thus, "the values of medical research
are the most universal values on earth, and they are the most
intimate and important values to every human being that lives. "''^

With medicine's unique acceptance by all people, the Rocke-
feller Foundation discovered what the missionaries also knew:
Medicine can be used to convert and colonize the heathen. In
1909 the Rockefeller philanthropies added pubHc health pro-
grams to their earlier efforts to develop public schools and
promote agricultural demonstration projects in the South in part
because medical care is so seductive to even the most reluctant
people.

In China, Gates switched from supporting religious missionar-
ies to building a Western medical system. This episode is
fascinating both because of the greater value that Gates, a man of
the cloth, placed on scientific medicine in promoting Western
influence and because of the unabashed imperialist motivations
he himself attributed to Rockefeller philanthropies abroad. In
1905 Gates urged Rockefeller, a frequent contributor to Baptist

Scientific Medicine II I 123

missionaries, to donate $100,000 to an organization of Congrega-
tional missions/'' "Now for the first time in the history of the
world," Gates explained to Rockefeller,

all the nations and all the islands of the sea are actually open and
offer a free field for the light and philanthropy of the English
speaking people. . . . Christian agencies as a whole have very
thoroughly invaded all coasts, all strategic points, all ports of entry
and are thoroughly entrenched where they are.

For Gates, transforming heathens into God-fearing Christians
was "no sort of measure" of the value of missionaries:

Quite apart from the question of persons converted, the mere
commercial results of missionary effort to our own land is worth, I
had almost said a thousandfold every year of what is spent on
missions. . . . Missionary enterprise, viewed solely from a commer-
cial standpoint, is immensely profitable. From the point of view of
means of subsistence for Americans, our import trade, traceable
mainly to the channels of intercourse opened up by missionaries, is
enormous. Imports from heathen lands furnish us cheaply with
many of the luxuries of life and not a few of the comforts, and with
many things, indeed, which we now regard as necessities.

Industrial capitalism, however, required not only raw materi-
als and cheap products. It also needed new markets for its
abundant manufactured goods. As Gates added to Rockefeller's
receptive ear:

our imports are balanced by our exports to these same countries of
American manufactures. Our export trade is growing by leaps and
bounds. Such growth would have been utterly impossible but for the
commercial conquest of foreign lands under the lead of missionary
endeavor. What a boon to home industry and manufacture!

The missionary effort in China was effective for a time in
undermining Chinese self-determination. Missionaries were the
velvet glove of imperialism, frequently backed up by the mailed
fist. Nevertheless, the missionary effort, promoted through
schools and medical programs, was still a very transparent
attempt to support European and American interests. As J. A.
Hobson, an English economist, noted at the time, "ImperiaHsm
in the Far East is stripped nearly bare of all motives and methods
save those of distinctively commercial origin.

"48

124 I Scientific Medicine II

In China, as throughout the world, the Rockefeller philan-
thropists soon concluded that medicine and public health by
themselves were far more effective than either missionaries or
armies in pursuing the same ends. The Rockefeller Foundation
removed the Peking Union Medical College from missionary
society control, established it under foundation direction, and
developed it into a completely secular, world renowned medical
center, spending a total of $45 million for the China medical
program.

In the Philippines, the foundation's International Health
Commission outfitted a hospital ship to bring medical care and
the "benefits of civilization" to the rebellious Moro tribes. The
foundation officers were ecstatic that such medical work made it
"possible for the doctor and nurse to go in safety to many places
which it has been extremely dangerous for the soldier to ap-
proach." Their medical work paved "the way for establishing
industrial and regular schools" and served as "an entering wedge
for permanent civilizing influences. ""^^ Thus, in subduing primi-
tive peoples and bringing them into desired colonial relations,
medical care has, in the words of foundation president George
Vincent, "some advantages over machine guns."^°

Given the openly imperiahst ambitions of the United States
early in this century, the Rockefeller philanthropy officers could
pubHcly acknowledge their use of medicine to integrate dissenting
people into industrial and capitalist society. Their domestic
medical programs had exactly the same ends, though Gates and
others were far more circumspect in discussing them.

Medicine was increasingly replacing religion as the intimate
arm of the social order. In education the teaching of values was
obvious, and attempts to reform the schools provoked angry
responses from a class-conscious society.^' In 1914 the National
Education Association's attacks on the Carnegie and Rockefeller
foundations were joined by many newspapers that condemned
the foundations for trying to turn "our schools into mills for the
manufacture of men and women made according to Rockefeller
and Carnegie specifications."" Medicine was more insidious.

For Gates to see medicine as a desirable replacement for
religion was indeed an interesting turn of events. Gates, it will be
recalled, was successively a Baptist minister, executive secretary
of the American Baptist Education Society, and Rockefeller's

Scientific Medicine II I 125

chief lieutenant in charge of the industriaHst's philanthropy and a
large part of his financial empire. Like other members of the
managerial stratum, Gates identified his own interests and des-
tiny with those of his employer.

Shortly after his move from the ministry to directing the
largest philanthropic and financial empire in the world, Gates'
views on religion began to change. He began to read the Bible
more critically and was soon convinced that "Christ had neither
founded nor intended to found the Baptist church, nor any
church; that neither he nor his disciples during his lifetime had
baptized; that the communion was not conceived by Christ as a
church ordinance, and that the whole Baptist fabric was built
upon texts which had no authority, and on ecclesiastical concep-
tions wholly foreign to the mind of Christ. "^^ Gates found himself
converted from Baptism to capitalism and scientism!

Medicine was a fundamental part of his new "religion." While
theology was being "reconstructed in the light of science," sci-
entific medicine was promulgating "new moral laws and new
social laws, new definitions of what is right and wrong in our
relations with each other." For Gates, the Rockefeller Institute
for Medical Research was a "theological seminary, presided over
by the Rev. Simon Flexner, D.D."'^

Gates did not fully explain the meaning of his metaphor, but it
seems clear that he viewed medicine as industrial society's
counterpart to rehgion, carrying moral precepts, "new duties,"
and the values of science to all people through its universal appeal
and irresistible intimacy. This function was understood by leading
members of the medical profession as well. Dr. John B. Roberts,
in his presidential address to the American Academy of Medicine
in 1904, laid out "The Doctor's Duty to the State." The physician
"should teach the laity that mental hygiene, or discipHne, is as
essential to proper living and happiness as physical hygiene,"
Roberts said. "Hygiene of the body gives a spirit of religious
toleration and calm" whilt "hygiene of the mind gives a healthy
digestion and a good income-making body and fits man for this
world as well as the next."^^ Scientific medicine was thus an ideal
instrument to help unify and integrate the new industrial society
and indeed a world order in the values and culture of science,
technology, and capitalism.

Western scientific medicine was an uncommonly good vehicle

126 I Scientific Medicine II

for United States efforts to dominate Latin America, Asia, and
Africa. But it was equally useful in bringing rural and technologi-
cally and industrially naive North Americans to accept the
domination of their lives by science and technology. Science had
provided a basis for rationalizing industry, for organizing produc-
tion consistent with the imperatives of profit and the growth of
capital, and simultaneously for undermining the arguments of
workers that the new technology eliminated their control over the
productive process. The application of science to industry in
fact depoliticized the whole productive process and created the
appearance that progress is technology's own imperative. Be-
neath that rule by technology lay the more fundamental impera-
tive— capitalism's need for economic growth. The march of
scientific and technological progress appears as an independent
variable on which essential economic growth depends. Science
and technology are developed mainly in ways useful to capitalist
society, and as Jiirgen Habermas has shown, "the development of
the social system seems to be determined by the logic of scien-
tific-technical progress. "^^

The same mystification that the technological "imperative"
pulls over the productive process is extended to all social spheres.
Mechanical engineers, led by Frederick Taylor, developed more
"efficient" ways of utilizing human labor in the factory, mainly by
separating mental from manual labor, reorganizing the labor
process under management's control, and substituting unskilled
for skilled labor wherever possible. Although it did not particu-
larly increase profits, Taylor's "scientific management" proved a
very effective form of social control.^'' It provided a moral
rationale for demanding obedience to capitalist values of hard
work and disciplined living. "Too great liberty," Taylor wrote to
Harvard president Charles EHot, "results in a large number of
people going wrong who would be right if they had been forced
into good habits. "^^ Housewives and mothers were similarly
exhorted to be more efficient, for the home was "part of the great
factory for production of citizens. "^^ Industrial and social
leaders of the Progressive era, whether themselves Progressives
or not, hoped to rationalize all social relations. The cult of
efficiency firmly established in American culture and intellectual
life the notion that technology must be served. Added to the

Scientific Medicine II I 127

already widespread view that science and technology are value-
free, the technological imperative became a powerful moral
force .

Corporation heads, presidents of elite universities, and phi-
lanthropists all joined in support of the new religion of science.
"Respect for the man who knows and loyalty to demonstrated
truth,'' preached Nicholas Murray Butler, president of Columbia
University, ''are characteristics of a civilization that is founded on
rock."^«

Research institutes were the temples of the new religion. The
Rockefeller Institute for Medical Research will be important in
three ways, Butler told the dignitaries assembled for the opening
of the institute's laboratories. It will add to mankind's knowledge
of medicine, it will help train needed scientists, and it "will help
spread abroad in the public mind a respect for science and for
scientific method." Each of these contributions is a public ser-
vice, he added, "but the last named is perhaps the greatest."^'

Scientific medicine, as part of the fervent campaign for
science, helped spread industrial culture, albeit a capitalist in-
dustrial culture, throughout the land and indeed the world. But
scientific medicine also developed into an ideological perspective
that legitimizes the great inequalities of capitalist societies and the
misery that results from the private appropriation of human and
environmental resources.

At one time, many physicians were in the vanguard of
progressive social reform movements. By the mid-1800s social
medicine was a highly developed field. Villerme, Buchez and
Guerin in France, Neumann, Virchow, and Leubuscher in
Germany, and dozens of lesser-known doctors studied the
economic, social and occupational causes of disease and worked
for reforms to eliminate them. Rudolf Virchow, one of the
fathers of modern cell physiology, argued that medicine "must
intervene in political and social life. It must point out the
hindrances that impede the normal functioning of vital processes,
and effect their removal."" Many physicians and sanitarians
identified and statistically documented inhuman and dangerous
working conditions, unemployment, miserable living conditions,
malnutrition, and general poverty as the major causes of the high
disease rates and early deaths among Europe's working classes.

128 I Scientific Medicine II

The failure of the revolutionary movement of 1848, in which
many of these physicians participated, did not halt their efforts to
change the conditions they opposed.

From the time of Pasteur and Koch, however, a more
conservative outlook dominated medical research. The clinical,
or medical, model focused attention on the individual, while
bacteriological research identified discrete, external, and specific
agents of disease. This perspective encouraged the idea of specific
therapies to cure specific pathological conditions, and it diverted
attention from the social and economic causes of disease. When
Koch presented his discovery of the tubercle bacillus to the Berlin
Physiological Society in 1882, many medical scientists did not
share Koch's view that this bacillus causes tuberculosis. Virchow
and others argued that since pathogenic micro-organisms lived in
healthy bodies, they are not the cause of disease. In their view,
invading micro-organisms could cause disease only after the host
organism had been weakened by some physiological or environ-
mental misery." Pasteur and Koch, nevertheless, won deserved
plaudits for their technical accomplishments; they and their
followers also won extensive financial support from their govern-
ments and wealthy individuals alike. In Europe and the United
States elite physicians perceived the opportunities opening before
them, and leading capitalists showed their appreciation for
medical science's ideological role.

Ideologues for capitalist society promulgated the insufficiency
of our mastery of nature, the inadequacy of our technological
development as the fundamental cause of misery. "The trouble
is," Gates wrote Rockefeller, "that the blanket of happiness
seems to be too short. If you pull it up at the head you expose the
feet; if you tuck it in on the one side you uncover the other side."
While there is probably no way to increase the "sum total of
human happiness," it is certain that the Rockefeller Institute "is
actually and enormously decreasing the sum total of human
misery. "^"^

It is clear whence comes the unhappiness. It comes not from
unequal distribution of wealth, sickening working and living
conditions, miserable and alienating work, tension caused by
frequent and prolonged unemployment, economic insecurity, and
competition among those whose sights are set on higher stations
in Hfe. "Disease is the supreme ill of human life," Gates

Scientific Medicine II I 129

proclaimed, "and it is the main source of almost all other human
ills, poverty, crime, ignorance, vice, inefficiency, hereditary
taint, and many other evils. "^^ It is not poverty or one's place in
the capitalist class structure that breeds misery; it is disease that is
the cause of the misery commonly attributed to poverty. Misery is
a technical not a social problem.

While "the great mass of charities of the world" go around
helping an individual poor family or indirectly "relieving or
mitigating such evils and miseries of society as are due mainly to
disease," the Rockefeller Institute reaches "the root of the evil"
and cleanses "the very fountains of human misery."^** This human
unhappiness can be eradicated through science and technology.
The same forces that helped create America's vast and growing
industrial base could be turned to eliminating her misery as
well. Gates thus joined with others in "medicalizing" all social
problems, defining them out of political struggle and even
religious morals, and giving them over to technical expertise and
professional management.

Rockefeller money did not support medical research that
investigated the relationship of social factors to health and dis-
ease. In its first decade, the Rockefeller Institute focused its
resources on chemistry, biology, pathology, bacteriology, physi-
ology, pharmacology, and experimental surgery.^'' It ignored the
impact of the social, economic, and physical environment on
disease and health. In later years, institute researchers touched
on the role of nutrition as a contributing factor in malaria and
some other parasitic and infectious diseases, but even then they
did not extend their conclusions to the actual social conditions in
which people lived. ^^ Of the more than 650 men and women who
contributed their skills to the Rockefeller Institute, few — with the
notable exception of Rene Dubos — seemed even to understand
the role of society and environment as forces affecting the very
diseases they studied.

This orientation to biological reductionism pervaded the
Rockefeller medical philanthropies. When Gates, Junior, and
other men in the Rockefeller Foundation decided to establish the
first public health school in the United States, they selected Dr.
Welch and Johns Hopkins University as their vehicles, knowing
the new school would have a heavy emphasis on the basic sciences
and not stray too far into social issues. ^^ Charles Wardell Stiles,

130 I Scientific Medicine II

the government zoologist who brought the hookworm to the
attention of the Rockefeller philanthropy and was named scientif-
ic director of the campaign to eradicate the parasitic disease,
exhibited a capacity for keeping his nose to the parasites and not
being distracted by social concerns. In an article on "The Chain
Gang as a Possible Disseminator of Intestinal Parasites and
Infections," Stiles offered not one word of criticism of chain
gangs per se. He limited himself to criticizing the lack of privies
and bemoaned the missed "opportunities for rigid discipline" that
could "make these penal institutions admirable schools in which
the State might easily give its charges some good lessons in
cleanUness, hygiene, and sanitation. "''^

GATES' DIGRESSION

Gates genuinely believed in technical solutions for problems
of social happiness. But there was another side to Gates. There
was a side that recognized the exploitation of labor by capital,
that felt compassion for the oppressed men and women of the
industrial working class. As a member of the board of directors or
chairman of the board of more than a dozen corporations, but not
a part of day-to-day management. Gates was never personally
involved in labor disputes. From his lofty heights at the top of the
Rockefeller financial and philanthropic empires. Gates had a
broad view of the needs of his class and a measured strategy for
meeting them.

In 1916, two years after the clamorous criticism over the
Ludlow massacre and a time when "labor is demanding more
wages everywhere," Gates asked himself the strategic question,
"shall one oppose this demand or favor it?" In a memorandum
for himself, Gates developed his position on "Capital and
Labor. "''^ First, unionism is selfish, violent, ignorant, perverse,
and mistaken, he believed. Through unions, labor demands "the
largest possible wage" and does "the least possible work"
whereas the public-spirited citizen, whether wealthy capitalist or
poor laborer, does the "largest possible service" and consumes
the "least possible amount of the public wealth" by accepting
private economy and saving.

Second, the object of labor should be to increase its real
wages, not merely get a jump on the next guy. "If a few crafts
become thoroughly unionized and secure their demands, it must

Scientific Medicine II I i31

be," Gates observed, "at the expense of all other crafts that are
not so unionized." Unions seemed to care little that raising the
wages of any one group will result in an increase in the cost of
living for all other groups since employers will pass on to
workers-as-consumers the increase in wages they grant. The wage
earner will have won his battle. Gates concluded, "not merely
when he has got his wages, but when he has so got them that they
will buy more." Higher wages without a higher cost of living is the
object, "and the only way under heaven in which that can be
done is by taking the wages out of the returns of the capitalist."
Gates believed labor's demand for a greater share of the
wealth was just. The laboring classes are "degraded" by the kind
of work they have to do, the amount of work required of them,
and "the deprivations that they have to suffer." The differences
between rich and poor, capitalist and laborer, "are due not to
heredity but to environment." The rich and aristocratic have no
purer blood than the "misshapen, ill-dressed, half-brutalized men
and women" who have worked the mines from childhood.

Shall we hate and despise and look down upon these people whom
our social system has made what they are, or shall we pity them and
shall we blame ourselves for having made them what they are, for
keeping them where they are, and for clothing ourselves with the
fruits of their unpaid labor?

Frederick Engels was not more eloquent!

Gates concluded that it was necessary and desirable for capital
to voluntarily reduce its return on investments from the prevail-
ing 5 percent to 2 percent and give the balance to the workers.

Cut down their hours of labor. Improve their living conditions. Give
them opportunities for music, for pictures, for whatever can
cultivate them in mind, whatever can beautify and adorn them in
body. Let us ourselves share to some extent the manual labor of the
world, and instead of a few rising to the top on the backs of the
many, let us undertake to build up society in all its parts as a whole
to a higher level.

Gates was moved not by compassion but by fear. He and
other members of America's ruling class were shaken by the
violent labor struggles, widespread working-class consciousness
and support for the Socialist party, and unrest among middle-
class Progressives. Most of this class antagonism was aimed at the

132 I Scientific Medicine II

great concentrations of wealth in the industrial monopolies and
the flaunting of wealth by the Vanderbilts and the Astors. Always
an advocate of inconspicuous consumption, Gates now privately
and momentarily looked to corporate-liberal social reforms to
head off the anticipated cataclysm.

With the entrance of the United States into the European
war, full employment and patriotism overwhelmed the Progres-
sive reform movement and justified repression of the Socialists
and militant working-class organizations. The immediacy of the
internal threat passed, and Gates abandoned even his private
thoughts of redistributing the wealth. Promoting physical and
social science research continued unaltered as the primary
foundation program for ameliorating misery although the junior
Rockefeller developed new programs in the arts to uplift the
people's culture.

A PERMANENT INVESTMENT

In addition to the expected material and political benefits of
medical science, Gates believed that endowing the Rockefeller
Institute was an ideal investment because of the permanence of
its findings. Each generation takes from the past and hands on to
the future "only the things that are proven to be permanently
useful." The "useless baggage" is dropped and left behind. The
one thing that "humanity has got to live with" is "old Nature and
her laws in this world," Gates told his friends at the Rockefeller
Institute. "These laws do not change and humanity will never
outlive them. Whatever we discover about Nature and her forces,
and incorporate into our science, that will be carried forward,
though all else be forgotten."''^

Despite his naive view of science. Gates viewed endowments
for scientific research as permanent social capital, an investment
that would continue to return dividends into the distant future.
Given his broad and long-range perspective of the needs of
capitalist society. Gates was very attracted to this feature of
scientific research.

Aside from its permanence, an investment by Rockefeller in
an institute for medical research would call forth more money
into medical research. This one act of philanthropy would "call
public attention to the importance of research" and encourage

Scientific Medicine II I 133

"many thoughtful men of wealth" to endow research in scientific
medical schools throughout the country.''^

In the end, private fortunes and public taxes alike flowed in
ever-increasing amounts into medical research. In 1911 Gates was
pleased that other rich men and women had indeed followed the
example of Rockefeller.'''^ By the mid-1920s Gates felt assured
that his strategy of encouraging public and private grants had paid
off. "Never before were the common people so ready to grasp the
extended hand of a liberal philanthropy," he told fellow trustees
of the Rockefeller Foundation, "and to cooperate by legal enact-
ment, liberal taxation, and private munificence."''^

All this financial support for medical science and the social
recognition heaped upon the scientific medical profession by
members of the upper class had given physicians a higher and
more secure status. Medical research institutes, Gates observed,
"have conferred dignity and glory upon medicine," with the
consequence that the medical profession was awakening "to a
proud and healthy consciousness of the dignity of its vocation."
Quite uncynically. Gates believed that "the elevation of the
medical profession" would further the interests of the profession
itself and help stabilize a sometimes shaky class structure.''^
Capitalist society was gaining another firm supporter as the
medical profession, cleansed of any social conscience, increasing-
ly recognized its duty to preserve the existing social order.

The philanthropic capitalists who supported medical science
believed it would do more than demonstrate their good works.
First, reductionist scientific medicine bore a striking, and not
incidental, similarity to the capitalist world view. Second, scien-
tific medicine would help integrate all members of society,
whatever their occupations or social standing, into an industrial-
technical culture, unifying the fragmented and often fragile
industrial-capitalist social order. Third, scientific medicine would
help replace the widespread class theories of misery with the
perspective that inequalities and unhappiness are technical
problems susceptible to engineering solutions, thus depoliticizing
medicine and legitimizing capitalism. Finally, scientific medicine
would help elevate the medical profession, encouraging a strong-
er identification of its members with the highest class in society
and the capitalist order itself.

134 I Scientific Medicine II

Gates believed that all these characteristics and consequences
of scientific medicine were good for society, just as he considered
socially beneficent the accumulation of wealth by Rockefeller and
his private decisions as to how it should be spent. Gates' views on
the benefits of scientific medicine and medical research were
cleariy shared in practice by other capitalists, government
officials, and members of the profession. Seldom laid out for
us with even Gates' minimal explicitness and coherence, their
perspectives were nevertheless clear in their programs and
articulated concerns. Gates' views on scientific medicine were
influential beyond the support given the Rockefeller Institute and
encouragement given to other programs of medical research.
Gates had the interest, the ideas, and the money at his disposal to
formulate and launch numerous programs to develop and extend
public health work and a major program to reform medical
education.

John D. Rockefeller, whose Standard Oil fortune financed the vast
philanthropies in his name, and John D. Rockefeller, Jr., who took over his
father's financial empire and philanthropies (1921). Rockefeller Archive Center.

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(1922). Rockefeller Archive Center

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Trustees of the General Education Board, the first Rockefeller founda-
tion, at a retreat in Rockland, Maine, in July 1915. Front row\from left:
Edwin A. Alderman, Frederick T. Gates, Charles W. Eliot (former
president of Harvard University), Harry Pratt Judson (president of
University of Chicago), Wallace Buttrick (executive officer of the Board).
Second row, from left: Wickliffe Rose (head of the Rockefeller public health
programs), Hollis B. Frissell, John D. Rockefeller, Jr., E. C. Sage, Albert
Shaw, Abraham Flexner. Third row, from left: George E. Vincent
(president of the Rockefeller Foundation), Anson Phelps Stokes, Starr J.

Murphy, Jerome D. Greene. Rockefeller Archive Center

CHAPTER

Reforming Medical
Education: Who Will
Rule Medicine?

By the end of the nineteenth century, American physicians were
still complaining bitterly of their "poverty" and low status in
American society. Those who had studied in Europe were
especially struck by the low esteem in which American doctors
were held compared with their German colleagues. The disparity
among physicians' incomes left some well off and some poor. As
the New York State Medical Society's journal put it, "There is a
handsome income for a few, a competence for the many, and a
pittance for the majority."^

Most professional spokesmen blamed the relative poverty of
doctors on "overcrowding" in the profession. The AMA Journal
argued in 1901 that through death and retirement of old doctors
and the increase in population, there was "room for nearly 3,300
new doctors each year," but the nation's 160 medical colleges
were producing nearly double that number.^

To deal with these problems, the medical profession adopted
an effective strategy of reform based on scientific medicine and
the developing medical sciences. Their plan was to gain control
over medical education for the organized profession representing
practitioners in alliance with scientific medical faculty. Their
measures involved large expenditures for medical education and
required a major change in the financing of medical schools.
Dependent on outside capital, the profession opened the door to

136 I Reforming Medical Education

outside influence. The corporate philanthropies that intervened
turned the campaign to reform medical education into a struggle
for control between private practitioners, on the one hand, and
academic doctors and the corporate capitalist class, on the other.
The conflict over who would rule medical education, to which we
now turn, was fundamentally a question of whose interests the
medical care system would serve.

PRACTITIONERS GAIN A FOOTHOLD

By 1900 the strategy evolved by elite physicians to reduce the
number of doctors, increase incomes, and raise the social class
base of the profession began to pay off. Medical research, despite
its limited financial support, was building pubHc confidence in
modern practitioners. Reforms were being pressed in some
leading universities, setting a new standard that others would
soon be forced to follow. Most states had established medical
licensing boards, however varied the standards they imposed.
The Illinois Board of Health in particular had begun a crude
evaluation of all medical schools in the United States and
Canada. Its report pubhshed in 1889 shook more than a few of
the 179 schools of the regular sect, twenty-six homeopathic,
twenty-six eclectic, thirteen miscellaneous, and thirteen schools
condemned as "fraudulent."^

All these advances did not yet resolve two major obstacles to
professional uplift. First, medical schools remained unregulated.
In the final quarter of the nineteenth century more than 114 new
schools had been founded. "^ The finances of medical schools
forced their faculties to oppose the reformers' strategy of
promoting scientific medicine to reduce output. Medical schools
were for the most part small profit-making enterprises, owned
mainly by their faculties. The only commodities they could sell
were medical degrees. Dependent for their survival as well as
their profits on student fees, the schools continued to pour forth
their products. Being proprietary in character but profitable only
to the faculty directly involved, they were unable to attract
outside capital or operating funds to support expensive teaching
and research programs necessary to scientific medical education.
Thus, "scientific medicine" was taught at only a few university
medical schools, and to a limited extent even in those — except for
Johns Hopkins, which was far from the norm.

Reforming Medical Education I 137

The second obstacle to implementing the reform strategy was
the organizational disarray of the profession itself. The AMA had
failed in its mission. It was by-passed in the last part of the
century by specialty societies which formed an aUiance in 1888 in
the American Congress of Physicians and Surgeons. The Ameri-
can Academy of Medicine and other groups were formed to fill
the reform role left vacant by the AMA. Membership in local and
state medical societies did not confer membership in the national
association, isolating it from the majority of practitioners. By
1900, only 8,400 physicians were members of the AMA.^ The
national leadership, without structural ties to state and local
societies, operated within a vacuum. Structurally weak, numeri-
cally small, dominated by traditional doctors only half-heartedly
committed to scientific medicine, the "voice of the medical
profession" seemed to have laryngitis.

Before the medical profession could secure reforms in medical
education, it had to strengthen its own organization. After some
stalled attempts at reorganization at the end of the nineteenth
century, the reformers won support from state medical societies
and completely reorganized the AMA at the 1901 convention in
St. Paul. The new organization, which continues to this day,
made the local medical society the basic unit of the association.
Individual physicians would join a local society. The local society
would send representatives to a state society, which in turn would
elect delegates to the newly formed house of delegates, the
legislative body of the national association. The president of the
AMA and a board of trustees were given substantial powers.
With the campaign skillfully managed by Dr. George H. Sim-
mons, the reform leader recently appointed secretary of the
AMA and editor of its Journal, and with the convention sessions
presided over by Dr. Charles A. L. Reed, the reorganization plan
was instituted without discussion.^

The reorganization created a hierarchical, representative
structure. The direct line of authority depended on the strength
of the local societies, always the strongholds of professional
interests. The new structure gave the state and national organiza-
tions stable leadership, which could more effectively coordinate
and mobilize resources for the profession's interests. The plan
was intended, and succeeded, to federate state societies into the
national association and, in the words of the committee on
reorganization, "to foster scientific medicine and to make the

138 I Reforming Medical Education

medical profession a power in the social and political life of the
republic."''

Doctors with a vision of uniting the profession behind a
campaign to elevate it moved from the wings onto center stage.
George Simmons invigorated the Journal with the mission of the
reform movement. AMA leaders asked physicians around the
country to spur legislative reforms, control state licensing boards,
and goad medical schools into altering their admission criteria
and curricula. The increased effectiveness of the AMA brought
support and membership from the many specialists who seemed
to have forgotten that they were physicians first and surgeons or
gynecologists second. Private practitioners of all types rose to
support the coordinated local-state-national vehicle for their
common interests. By 1910 some 70,000 doctors were AMA
members, more than eight times the membership at the turn of
the century.

Although many rank-and-file physicians were unhappy with
the centralized control emanating from the AMA's Chicago
offices and with the reform strategy itself, most physicians
undoubtedly supported the movement.^ Most physicians resented
the economic and social conditions of the profession, particularly
when they realized that things could be better. They understood
that competition among physicians for a greater share of the
available medical dollars would help only a few and that the
interests of every physician were tied to the interests of the
profession as a whole.

The reform leadership, representing a coalition of private
practitioners and medical school faculty, articulated the desires of
most doctors for financial and social uplift, and offered a viable
strategy for achieving them. This coalition controlled the *AMA
from the end of the nineteenth century until World War I, sharing
the association's presidency and jointly implementing its reform
strategy.^

COUNCIL ON MEDICAL EDUCATION

Once in control of the reorganized AMA, the reformers
launched their most effective tool for transforming the profes-
sion. In 1904 the AMA replaced its temporary committee on
medical education with a permanent Council on Medical Educa-

Reforming Medical Education I 139

tion, headed by the energetic and resourceful Arthur Dean
Sevan, a successful surgeon and part-time professor at Rush
Medical College in Chicago. The new council was armed with a
staff to help it exert "a national influence and control of medical
education. "^°

To facilitate that control, it invited state licensing boards to a
national conference in 1905 to review the status of medical
education and set standards. There the council adopted "an ideal
standard to work for in the future" — one that would raise U.S.
medical education to the same basis as England, France, and
Germany — and "a minimum standard for the time being." The
temporary standard was: (1) a preHminary education of four
years of high school, (2) a four-year medical course, and (3)
passing an examination before a state licensing board.''

Bevan urged local and state medical societies to become more
active in the reform movement and to see that "the right sort of
men" were appointed to the Hcensing boards. Within two years
the state medical societies, under the guidance of the Council on
Medical Education, dominated the state boards. Through the
influence of the state societies and direct contact by the council,
the licensing boards increasingly became agents of the council's
plan of action.'^

The more the state boards cooperated with the council to
accept diplomas only from medical schools "in good standing"
and to gear their examinations to the curricula of scientific
medical schools, the more uncertain was the future of all medical
schools except those elite schools already geared to the needs of
scientific medicine. Those schools that could tap sufficient
resources to provide laboratories, "cHnical material," and scien-
tifically trained faculty had a reasonably good prognosis. The
graduates of such schools were allowed by the state boards to
take their licensing exams, and they had a fairly good chance of
passing. There was little incentive for students to attend and pay
the fees of unapproved schools and schools whose graduates
tended to flunk the licensing examinations. But state boards were
not uniformly in the hands of the state medical societies, so the
council developed a new tactic to upgrade medical education,
close more schools, and develop a controlling role for itself in the
field.

In 1906 the council inspected every one of the country's 160

140 I Reforming Medical Education

medical schools. Each school was personally visited by council
secretary Dr. N. P. Colwell or another council member and was
rated on the percentage of its graduates who passed the state
licensing exams, enforcement of preliminary education require-
ments, curriculum, laboratory and clinical facilities and instruc-
tion, laboratory science faculty, and whether the school was run
for a profit. Reports on each school were sent to the state
licensing boards, and the percentage of each school's graduates
who failed state board examinations was published in the AMA
Journal. ^^

In 1907 the council divided medical schools into classes A, B,
and C, depending on their ratings. Of the 160 schools inspected,
eighty-two were rated as class A medical colleges, forty-six were
class B, and thirty-two class C. The impact of the council's report
was significant. Fifty schools agreed to require one year each
of college physics, chemistry, biology, and a modern language
before admission to the medical program. Sensing doom, a
number of schools consolidated with other medical schools in
their cities, combining facilities and staffs. Other schools realized
that they did not have the resources to survive the heightened
competition. By 1910 the number of schools had fallen from a
high of 166 to 131.^"

While the practitioner reform leaders were pressing for stiffer
standards within medical education, the medical schools them-
selves were doing their best to survive. The Association of
American Medical Colleges (AAMC), representing about a third
of all American medical colleges, sought to differentiate its
member schools — "the better classes of medical colleges" — from
run-of-the-mill schools. They were concerned that rising stan-
dards in admission and instruction would bankrupt even the best
schools. As the representative of the elite portion of scientific
medicine's rear guard — the schools themselves — the AAMC
favored cooperation between itself, the Council on Medical
Education, and the association of state licensing boards. The
AAMC sought uniform minimum standards for all states so that
each state's requirements of medical schools would come "up to,
but not beyond," the standard recommended by a joint commit-
tee of all three bodies. ^^

Ahhough the Council on Medical Education had neither legal
powers nor authority within the profession, council chairman
Bevan, AMA secretary and Journal editor Simmons, and other

Reforming Medical Education I 141

professional reformers well understood the role of leadership and
the powerful advantage of articulating a strategy consistent with
historical forces. Science's time had arrived in medicine: A
middle and upper class whose dominance depended on industri-
alization was receptive to what scientific medicine advocates
within the profession offered. State licensing boards, under the
influence or in the hands of the medical societies, assured the
dominance of scientific schools and the competitive disadvan-
tages of economically weaker schools. The cost of a scientific
medical education was shattering the financial arrangements of
proprietary medical schools. The council could not order schools
closed, but it ralHed poHtical allies in the state boards and the
forces of the marketplace to wreck the ancien regime.

MONEY FOR MEDICAL EDUCATION: WHO WILL PAY?

The reforms initiated and pressed by the AMA leadership
were clearly having their desired impact. But the profession's
power to accomplish its ultimate goals was limited. Scientific
medicine was an expensive affair. Nearly all medical schools at
the end of the nineteenth century relied for most of their support
on students' tuition fees. Most independent medical colleges and
many of those nominally associated with universities had no other
source of income. Yet the teaching of scientific medicine required
expensive laboratory buildings, a teaching hospital and teaching
cHnic, and equipment. Some of these facilities could be obtained
from local men and women of wealth if faculty members had
fashionable private practices. Some facilities could be had if the
medical school was affiliated with a well-endowed university.
However, more than facilities were needed.

The largest operating expense for a scientific medical school
was the faculty to teach the laboratory science courses. A
practitioner might be good enough to teach chnical courses, but
he usually was not expert enough in physiology, bacteriology, or
pathology. The basic medical sciences had to be taught by
medical scientists who were specially trained in that area and
whose on-going research kept them abreast of developments in
their field. These faculty had to devote their full time to teaching
and research, and they were the largest operating expense of a
turn-of-the-century scientific medical school.

The cost of a scientific medical education was beyond the

142 I Reforming Medical Education

means of students. "It costs more to educate a medical student,"
Bevan noted, "than he can pay in the way of fees.'"^ The capital
investment and operating costs for scientific medical education
were also beyond the means of the profession itself. Wealthy
physicians might provide a small portion of the capital for a
medical college, but the reformers recognized early that most of
the capital for scientific medical schools would have to come from
outside the profession. ^^ States might be persuaded to support
state institutions, but most medical schools and universities — and
certainly the most elite — were privately controlled. "The public
must be taught the necessities and the possibilities of modern
medicine," Bevan argued, and philanthropists must be shown
that medicine deserves their endowments. ^^ Because of the
amounts involved, much of the money would have to come from
the fortunes of the very wealthiest men and women in America.
The medical reformers were well aware of the dangers of help
from the outside. "Rich men may injure the cause of medical
education," the AMA Journal warned in 1901, unless their giving
is directed by the profession itself. ^^ With the blessings of the rest
of the profession's leadership, Bevan took on the task of getting
and guiding endowments for medical colleges. "We must secure
for them state aid and private endowment," he told the council's
1907 national conference. "We must start an active, organized
propaganda for money for medical education."^"

HELP FROM THE CARNEGIE FOUNDATION

Impressed with the impact of the council's own survey, Bevan
turned to the Carnegie Foundation for the Advancement of
Teaching. He sought the foundation's help, not just to replicate
the council's own work, but to add to their campaign the
foundation's developing prestige and image of "objectivity."
Bevan understood the foundation's potential for molding public
opinion and providing a credible blueprint for philanthropists to
follow while channeling their money into medical education. It
was also clear that an agency outside the profession could openly
attack medical schools that resisted reorganizing themselves or
going out of business without once again spHtting medical school
faculty off from the reform leadership. At the council's first

Reforming Medical Education I 143

national conference in 1905, Bevan criticized proprietary medical
schools as an obstacle to reform, but he felt compelled by the
need for diplomacy to urge leniency because of the "property and
professional interest" invested in them.^^

In 1907 Bevan invited Henry S. Pritchett, president of the
Carnegie Foundation for the Advancement of Teaching, to
examine the survey materials collected by the council. Meeting at
the Chicago Club, Bevan and Pritchett saw eye-to-eye on the
value of a Carnegie-sponsored study of medical education. For
Bevan the Carnegie study would be the big guns in the campaign
for medical education reform. Pritchett was sympathetic to that
concern, but mainly in the context of the foundation's program to
reform and rationalize the nation's colleges and universities,
including its professional schools. ^^

The foundation had been established in 1905 to upgrade the
status of college teachers while creating a uniform system of
higher education. Out of discussions between Andrew Carnegie
and Pritchett emerged a plan to advance teaching by the carrot-
and-stick method. The new foundation provided an initial en-
dowment of $10 million to support a retirement program for
college teachers. The pensions would be given without any cost to
the institution or its individual teachers, but each college must
meet the conditions laid down by the foundation. Denomina-
tional colleges were not eligible for the pension plan. Religion
was, of course, an important moral force, but it would not pro-
mote the universality of science; colleges controlled by compet-
ing denominations would be more concerned with propagating
the faith than with training scientists and engineers. Denomina-
tional colleges, hoping to make themselves more attractive to
faculty, besieged the foundation with inquiries about how to
amend their charters to make themselves eligible for free pen-
sions. In addition, the foundation imposed academic and financial
requirements designed to force the poorer colleges to match the
academic standards of the better colleges and to make higher
education follow a uniform pattern throughout the country."

Thus, Bevan's request for a study of medical schools fit well
with the foundation's general program and provided an oppor-
tunity for the foundation to move into reforming professional
education. Pritchett discussed the proposed study with Charles
Eliot, president of Harvard and a trustee of the Carnegie

144 I Reforming Medical Education

Foundation, Rockefeller's General Education Board, and the
Rockefeller Institute for Medical Research. He also talked with
Dr. Simon Flexner, director of the Rockefeller Institute. Flexner
suggested a director for the study, his brother Abraham. The
suggestion meshed well with Pritchett's conception of the study as
contributing to the reform of higher education. ^"^

Abraham Flexner was a professional educator. He got his
bachelor's degree from Johns Hopkins in two years of diligent
and hard work. He later founded and ran his own college
preparatory school in Louisville and afterwards spent a year in
advanced study in education at Harvard. While in Heidelberg in
the summer of 1908, Flexner wrote The American College, which,
in his own words, "fell quite flat." Late in the summer of 1908
Flexner returned from Europe unemployed and "prepared to do
almost anything." Hoping to get a job, Flexner initiated a
meeting with Pritchett. They talked about higher education and
its problems and found they agreed on the necessity for reform.
"When I next saw him," Flexner later recalled, "he asked me
whether I would like to make a study of medical schools."
Flexner was enthusiastic, "but it occurred to me that Dr. Pritchett
was confusing me with my brother Simon at the Rockefeller
Institute, and I called his attention to the fact that I was not a
medical man and had never had my foot inside a medical school."

"That is precisely what I want," replied Pritchett. "I think
these professional schools should be studied not from the point of
view of the practitioner but from the standpoint of the educator. I
know your brother, so that I am not laboring under any con-
fusion. This is a layman's job, not a job for a medical man."^^

A report on medical education by a physician would lack
credibility, and it would feed the divisions between practitioners
and part-time medical school faculty. Moreover, Pritchett, while
certainly not adverse to aiding medical professionals, wanted
medical education integrated into a general system of education.
A report by an educator sold on the importance of a scientific
medical profession would provide both the right perspective and
credibility.^^

At their November 1908 meeting, Pritchett asked the Carne-
gie Foundation trustees to authorize the study and appropriate
the necessary funds. With their approval, Flexner immediately
began his study. ^"^ Bevan directed the reform campaign, Pritchett

Reforming Medical Education I 145

financed it with Carnegie's money, and Abraham Flexner
implemented it.

THE "FLEXNER REPORT"

A scholarly technician, Flexner began by reading up on the
history of medical education in Europe and America. He went to
Chicago to discuss the study with George Simmons, secretary of
the AMA and editor of its Journal. He also met with Bevan and
Colwell, secretary of the Council on Medical Education. He read
Colwell's reports on medical schools and found them "creditable
and painstaking documents" but "extremely diplomatic."

Flexner then visited his alma mater, Johns Hopkins, where he
met with the medical school's leading faculty members, Drs.
Welch, Halsted, Mall, Abel, and Howell. Flexner found Hopkins
"a small but ideal medical school embodying in a novel way,
adapted to American conditions, the best features of medical
education in England, France, and Germany." Hopkins became
the living model for Flexner. "Without this pattern in the back of
my mind, I could have accomplished little. "^^

Flexner saw his mission as translating the Hopkins medical
school into a standard against which to judge all other medical
education in the United States. All others paled before this "one
bright spot." Flexner's praise of Hopkins grew ecstatic:

It possessed ideals and men who embodied them, and from it have
emanated the influences that in a half-century have lifted American
medical education from the lowest status to the highest in the
civilized world. All honor to Oilman, Welch, Mall, Halsted, and
their colleagues and students who hitched their wagon to a star and
never flinched!"

Flexner visited every one of the 155 medical schools in the
United States and Canada. Colwell, of the AMA, went with him
to most of them. In nearly all cases, the school administrators and
faculty laid bare the facts of their existence — facilities, laboratory
equipment, numbers of faculty and their qualifications, numbers
of students and their preparation, the curriculum, patients avail-
able as teaching material, income from student fees, and endow-
ments.^°

Even administrators and faculty who knew their schools were

146 I Reforming Medical Education

deficient in many assets the Council on Medical Education
believed important permitted Flexner and Colwell access to
facilities, staff, and account books. Many of the schools were run
by doctors who were committed to elevating the profession and
saw the importance of creating scientific medical schools. Even
more persuasive in opening medical schools to inspection was
that deans, faculty, and trustees of most medical schools be-
lieved that Flexner's visit "would be followed by gifts from Mr.
Carnegie to set things right." Whatever fear the medical school
deans and faculty had of the consequences of pubHc criticism,
they understood that failure to comply with the Carnegie study
would result in their rapid demise. The market for medical
students was very competitive, and bad publicity would do
serious injury. But riskier still were the dynamics of the competi-
tive market. If many competing medical schools that cooperated
with the Carnegie study got a large advantage — for example, a
new laboratory or an endowment — the financial collapse and
demise of the disadvantaged was assured. ^^

Some colleges resisted inspection, but resistance was grounds
for suspicion. To the recalcitrant medical schools, Pritchett let it
be known that "all colleges and universities, whether supported
by taxation or by private endowment, are in truth public service
corporations," and, therefore, the foundation, the medical pro-
fession, and the public had a right to know about their finances
and educational practices. Rather than fear intervention by out-
siders, the leading reformers in the profession savored this attitude
of the foundation. Not only did this attitude support their cam-
paign, but it recognized medicine as a vital societal function. ^^

flexner's findings

Flexner visited the medical schools and wrote his report in the
space of eighteen months. His whistle-stop tour and his acerbic
comments on what he saw gave him a reputation, even among
medical reformers, for being "erratic" and "hasty in judgment."
The medical faculty at Harvard were insulted and in return cast
aspersions on his ability while the faculties at lesser schools
merely bristled."

Not coincidentally, Flexner's criticisms of American medical
schools and his recommendations for reform were perfectly

Reforming Medical Education I 147

consistent with those of the leading medical profession reformers.
Flexner attacked medical schools for producing too many doc-
tors, for requiring too little education before admission to
medical school, for having inadequate facilities and faculty and
providing inadequate training, and for creating a social composi-
tion for the medical profession that was inappropriate to its
important social role.

Flexner and Pritchett both attached great importance to
medicine's changing role in society. The physician's function
in society, traditionally "individual and curative," was rapidly
becoming "social and preventive. "^"^ If "society relies" on doctors
for important social functions, then "the interests of the social
order" must be considered first in any public policy for reforming
the profession. ^^ What was wrong with the medical profession
from society's point of view?

Overcrowding was the most serious problem with the profes-
sion, according to Pritchett and Flexner. If Germany could thrive
with one doctor for every 2,000 inhabitants, then the United
States, with an average of one doctor for every 568 persons,
suffered from a severe oversupply of physicians. Overcrowding
forces professionals into competition with one another, fighting
for a relatively inelastic market of patients and encouraging one
another to perform unnecessary services to increase their in-
comes. Overcrowding "decreases the number of well-trained men
who can count on the profession for a livelihood," reducing the
attractiveness of a medical career to competent men. "The
country needs fewer and better doctors," Flexner argued, and
''the way to get them better is to produce fewer. "^^

The main reason for the overcrowding of the profession, as
well as for its generally low standards, was the prevalence of
"commercial" medical schools. Only fifty of the 155 medical
colleges were integral parts of universities. The rest, whether
independent or nominally affiHated with a university, were in
reality run by the medical faculty alone without any outside
control. These proprietary schools depended on students' fees,
which were divided up among the local practitioners who were
lecturers in the school. Many of the faculty fattened their incomes
through "the consultations which the loyalty of their former
students threw into their hands." Faculty chairs in the commer-

148 I Reforming Medical Education

cial schools were bought and sold, sometimes for as much as
$3,000.^^

Commercial medical schools dragged down medical education
in its entirety, argued Flexner. Their incomes based entirely on
student fees, the schools tended to admit as many students as
possible and to reduce their expenses as much as possible. Since
lectures were the cheapest form of education — in which the
income from student fees went directly to the faculty instead of
being invested in buildings, laboratories, or equipment — medical
education came to consist almost entirely of lectures until the
1880s. The necessity of laboratory and clinical training for the
scientific medical doctor greatly strained the resources of propri-
etary medical schools. The choice was clear. "The medical pro-
fession is an organ differentiated by society for its own highest
purposes, not a business to be exploited by individuals according
to their own fancy. "^® To assure its public service character,
medical schools must be made integral parts of universities.

The social importance of the medical profession meant not
only that medical education should not be left to proprietary
organization, but that it should be reserved for those who could
afford "a liberal and disinterested educational experience." Pro-
prietary medical schools, with their admission requirements of
four years of high school or its "equivalent," attracted "a mass
of unprepared youth . . . drawn out of industrial occupations
into the study of medicine." Neither "the crude boy" nor "the
jaded clerk" were suitable material for a career in medicine. ^^
Flexner proposed a minimum two years of college for admission
to medical school at a time when only 15 percent of the high
school age population was enrolled in high school and only 5
percent of the college age population was enrolled in a college or
university. "^^

Consistent with the racism of his period, Flexner argued that
"the practice of the Negro doctor would be limited to his own
race." However, "self-protection not less than humanity" should
encourage white society to support improved training for black
physicians: "ten miUions of them live in close contact with sixty
million whites." In addition, the importance of black physicians
in facilitating "the mental and moral improvement" of their race
required creating an ehte core of scientific black doctors.
Applying the formula of "the fewer, the better," Flexner

Reforming Medical Education I 149

recommended that of seven black medical schools then in
existence, only Meharry and Howard be continued/*

Flexner also recommended closing the three women's medical
colleges. Schools for women alone were unnecessary and ineffi
cient since ''medical education is now . . . open to women upon
practically the same terms as men." If the number of women
medical students was dechning, it demonstrated a lack of either
"any strong demand for women physicians or any strong ungrati-
fied desire on the part of women to enter the profession," or
both. Flexner seemed to believe, with most of his peers, that
women are seldom equipped for the mental rigors of medicine
and, if middle or upper class, women make better patients than
doctors."*^

The very clear consequence was to be an across-the-board
reduction in the production of doctors, with especially large
reductions in the numbers of poor and working-class young men,
blacks, and women entering the medical profession. The social
class and status of medicine would be raised, together with the
incomes of physicians, to a level appropriate to its role in society.
These changes were made necessary, according to Flexner, by the
requirements of scientific medicine as well as by medicine's new
social role.

Flexner found that only twenty-three of the country's 155
medical schools required two or more years of college prelimi-
nary to medical school. And 132 schools admitted students with a
high school education or its "equivalent." The latter would be a
tolerable "temporary adjustment" where there were not enough
college students to fill the medical school openings, but two years
of college provides "the varied and enlarging cultural experi-
ence" necessary to a modern physician.'*^

Instruction in biology, chemistry, and physics should be
required before the student could enter medical school. The
medical college curriculum was to proceed from there. In the first
two years the student would study anatomy, physiology, bacteri-
ology, pathology, and pharmacology. With this thorough ground-
ing in the laboratory sciences, the student would spend his or her
third and fourth years in supervised clinical study. Only the better
medical schools, affiUated with universities and requiring two
years preliminary college education, provided the model curricu-
lum.*^

]50 I Reforming Medical Education

Flexner's report thus sought to place medical education on a
uniform basis consistent with the needs of scientific medicine and
to elevate the status of the medical profession to a position
consistent with its important social role. This mission required
eliminating both proprietary schools and the lower classes,
restricting the opportunities of women and blacks to enter the
practice of medicine, as well as increasing the preliminary
requirements and standardizing the curriculum into a graded,
four-year program. Reducing the supply of physicians was no
mere by-product of Flexner's program. "The improvement of
medical education cannot," he argued, "be resisted on the
ground that it will destroy schools and restrict output: that is
precisely what is needed.'"*^

Flexner's analysis and recommendations were strikingly like
those of the leading reformers of his time within the profession.
For at least a decade before Flexner's report was published in
1910, medical journals argued that the profession was overcrowd-
ed and that improving medical education was the best means of
restricting output. "We raise the standard of medical education
year by year, yet the mushroom colleges do not go," Frank
Lydston complained to his colleagues in 1900. "We have done the
best we could to breed competition by manufacturing doctors.'"*^

In 1901 the AMA Journal warned that the growth of the
medical profession should be stemmed "if the individual mem-
bers are to find the practice of medicine a lucrative occupation.'"*''
And in 1905, Council on Medical Education member V. C.
Vaughan told the council's first national conference that "the
supply quite equals the demand, and for this reason the time is
propitious for raising the barrier to admission one notch high-
gj. "48 yj^g argument that medical students should be drawn only
from the better classes hkewise did not originate with Flexner."*'

At their 1905 national conference and in the following year,
the council had urged a temporary preliminary education require-
ment of high school graduation and one year each of university
physics, chemistry, and biology. The council had also recom-
mended a curriculum of four years, with anatomy, physiology,
pathology, pharmacology, and bacteriology in the first two years
and supervised clinical study in the last two.^°

Strict university affiliation had been a cornerstone of the
medical education reform movement for at least forty years by

Reforming Medical Education I 151

the time Flexner published his report. The university affiUations
of most nineteenth-century medical colleges provided the medical
school with prestige and legitimacy and gave the university credit
for having a medical school, but there were few administrative or
academic ties. Charles Eliot, when he assumed the presidency of
Harvard in 1869, asserted the authority of the university over the
medical faculty and turned the medical school over "like a
flapjack," in the words of Oliver Wendell Holmes, then a faculty
member in the school. Eliot's new regime raised entrance re-
quirements, instituted scientific medical courses, and forced the
faculty to submit to the normal university administrative and
academic authorities. Eliot hoped to attract an endowment by
demonstrating that the medical school was no longer a private
venture "for the benefit of a few physicians and surgeons." His
plan was successful. Subordination of the medical school to the
university became a key plank in the platform of medical
education reformers.^'

The coincidence of Flexner's and the profession's analysis and
recommendations could be due to the compelling claims of
scientific medicine. That is, any two investigators of the medical
profession at that time might have been led to more or less the
same conclusions because, within the strategy of developing
medical science, the deficiencies of the profession and medical
training were obvious. But the relationship of Flexner to the
profession was close. His brother was director of the country's
leading medical research institute, and he consulted at great
length with the AMA leadership throughout his study.

In fact, it was explicitly understood from the beginning that
the Carnegie study would be part of the council's campaign,
lending credibility to the council's plans for reforms. Six months
before Flexner's report was published, Pritchett, president of the
Carnegie Foundation, wrote Bevan:

In all this work of the examination of the medical schools we have
been hand in glove with you and your committee. In fact, we have
only taken up the matter and gone on with the examination very
much as you were doing, except that as an independent agency
disconnected from actual practice, we may do certain things which
you perhaps may not. When our report comes out, it is going to be
ammunition in your hands."

152 I Reforming Medical Education

Bevan, anxious to start getting mileage out of the Carnegie
study, wanted Flexner and Pritchett to speak at an AMA meeting
several months before the report was to be published. Pritchett
was concerned that if the conspiracy between the foundation and
the AMA was made visible — and especially before publication —
the report would lose some credibility, and the foundation's
"disinterested" image would be tarnished. "It is desirable," he
privately added to Bevan, "to maintain in the meantime a posi-
tion which does not intimate an immediate connection between
our two efforts."

This sort of deception increased the credibility of the Flexner
report, but it was not essential to the transformation underway. It
merely helped along the social and economic forces already in
motion.

IMPACT OF THE REPORT

When the Flexner report was published as "Bulletin Number
Four," the Carnegie Foundation found itself the object of "more
stone-throwing than was to be expected" for its association with
the "Medical Trust" — the AMA and its Council on Medical
Education. Pritchett was embarrassed by the "somewhat dogmat-
ic appearance" of the report which lent credibility to charges of
collusion with the AMA, but Bevan and the AMA felt "very
much flattered by such an association." Regardless of how
Pritchett felt about the public impugning of the foundation's
reputation, neither he nor the foundation backed down from its
support for the AMA."

Pritchett did not consider that aligning his foundation with the
medical professionals might compromise the foundation's larger
objectives. Only in 1913 did he begin to see a conflict developing
between the profession's objectives of closing medical schools
right and left and the foundation's goals of rationalizing higher
education and providing for a professional group to fulfill an
important function in society. The council's demand for one year
of college preparation for admission to every medical school in
the country did not take account of regional differences and
especially the relative backwardness of the South. Pritchett
feared that the very classification scheme that so impressed him in
1907 was being used to set medical education off from the rest of

Reforming Medical Education I 153

the school system, rather than gradually pressuring the lower
schools to meet the preliminary training needs of the medical
schools. He accused the council of disregarding "the educational
results which the school system itself can turn out," and he
warned that "your power will quickly disappear if you advocate
courses which are educationally indefensible."^"^

Pritchett gradually came to realize that the medical profes-
sion's interests would lead it to actions that conflicted with the
interests that the foundation wanted to further. By 1918 it was
clear to Pritchett that the AMA would wreck all medical edu-
cation for blacks if left to its own devices. Believing in the
social importance of black doctors among black people, the
Carnegie Foundation was supporting the Meharry medical school
while the council was rating it a class B school. Pritchett protested
the "grave injustice done to the negro [sic] schools" by the
council's de facto policy of not extending to them the same
leniency given to white schools in the South. The policies of the
zealous AMA reformers were closing medical schools and
disrupting the attempts to build a uniform school system, all
without regard for the public interest as defined by the leading
foundations. Pritchett threatened to call a meeting of his and the
Rockefeller foundations, representatives of some licensing
boards, and the dozen "stronger medical schools" to force the
council to "revise its present classification of medical schools.""
Within a decade of his cordial meeting with Bevan at the Chicago
Club, Pritchett had come to view the council's power in much the
way Dr. Frankenstein viewed his own creation.

Pritchett's dismay at the council's use of its power was
undoubtedly made more painful because of the influence exerted
by the Carnegie report. It is sometimes forgotten that the report
did not create the movement for medical school reform. The
movement for scientific medical education had borne its first fruit
four decades earlier. Charles Eliot had led the reform of the
Harvard medical school beginning in 1870. Also in the seventies
the first teaching hospital was founded by an American university
in Michigan, state medical licensing boards were reestablished,
and the Illinois board had begun a series of influential reports
on medical schools. The Council on Medical Education's own
survey of medical schools in 1907 was, of course, the model for
Flexner's study and had a substantial impact itself. The pro-

154 I Reforming Medical Education

fession's increasing control of state boards made rapid "progress"
possible. ^^

Flexner noted that even before his study was published, great
strides had been made in reforming medical education. Medical
school programs had been extended to four years, clinical
teaching had been added to didactic methods, laboratories were
widely available and had been expanded, admission standards
had been adopted and were Hved up to with varying degrees of
commitment, and state boards — the police power behind the
reform movement — had been created in most states. The conse-
quences of these changes were admirable. The number of medical
schools was declining, he noted, and independent and commer-
cial schools were rapidly giving up the ghost."

Flexner's report thus aided a process already underway. The
rate of consolidation and elimination of medical schools was as
rapid before the report as after. Between 1904 and 1915 some
ninety-two schools closed their doors or merged, forty-four of
them in the first six years to 1909 and forty-eight in the second six
years to 1915.^^

Cut off from sources of funding, in part by Flexner's
recommendation, the five disapproved medical schools for blacks
soon closed. With racism as rampant in white medical schools and
medical societies as throughout the rest of the society, medical
care for blacks declined even further. In 1910 there was one black
doctor for every 2,883 black people in the United States
(compared with one physician to ever>' 684 people for the nation
as a whole), but by 1942 the ratio had grown further to one black
physician for every 3,377 black people.^' Flexner's attitude
toward women in medicine, more extreme than the views of
many of his contemporaries, certainly contributed to keeping
women at an average of less than 5 percent of all medical
graduates from 1900 until World War II. Today women constitute
about a fifth of all medical students and blacks about 6 percent,
both far less than their proportions in the population but
substantially higher than a decade earlier because of the recent
struggle for an affirmative action policy in medical school
admissions.

Flexner's report also contributed to eliminating sectarian
medical colleges. Scientific schools no longer called themselves
"regular." By 1932 Arthur Dean Bevan was able to say apprecia-

Reforming Medical Education I 155

tively, "We were, of course, very grateful to Pritchett and to
Flexner" for enabling "us to put out of business" the homeopath-
ic and eclectic medical schools in existence in 1910.^^ Flexner's
contribution was not as substantial as Bevan remembered: The 31
homeopathic and eclectic schools surviving in 1910 were down a
third from their number in 1900. ^*

The report's direct impact on the profession was moderate,
but its consequences were indirectly monumental. As Flexner
himself pointed out, the report spoke to the public on behalf of
the medical reform movement. It helped "educate" the public to
accept scientific medicine, and, most important, it "educated"
wealthy men and women to channel their philanthropy to support
research-oriented scientific medical education. The Flexner
report and the Carnegie Foundation's support brought economic
and political power into the war as partisans of the "regular"
doctors cum-scientific medical men.

Within a year following the report's publication, the General
Education Board entered the fray in earnest. By 1920 the GEB
had appropriated nearly $15 million for medical education and by
1929 a total of more than $78 million. By 1938 contributions from
all foundations to medical schools exceeded $150 million. ^^ The
frequently used matching grant policy, requiring the recipient
institution to raise an equal sum itself, greatly increased the
impact of their funds. Because the foundation grants were
conditional on specific reforms in the medical schools, the
foundations exerted a major influence. They forced schools to
adopt a research orientation, required teaching hospitals to
subordinate their autonomy and patient care to the needs and
authority of a university medical school, and established salaried
clinical professorships.

The foundations' power was in providing the outside capital
for the reform of medical education and the profession itself. As
the suppliers of that capital, they were able to dictate terms to the
profession. In the earliest years, however, it was the profession
that defined the goals and the strategy. The Carnegie Foundation
had provided its resources to the leading medical professionals.
The Flexner report united the interests of elite practitioners,
scientific medical faculty, and the wealthy capitalist class. The
report validated the elite professionals and enabled them to speak
to philanthropists with a single voice, amplified by the Carnegie

156 I Reforming Medical Education

Foundation. Without the Carnegie report, the fears of "misdi-
rected generosity," voiced by the AMA Journal in 1901,^^ might
have been even more justified than they turned out to be.

THE GENERAL EDUCATION BOARD:
MEDICAL EDUCATION GETS
A DIFFERENT DRUMMER

While Pritchett was parrying blows from critics and soaking
up support from the medical profession reformers, Flexner was
sent abroad by the foundation to study European medical
schools. Back home in New York in the spring of 1911, while he
was writing the report of his personal investigation, he was
invited to lunch by Frederick T. Gates.

As Flexner recalled the momentous meeting years later,
Gates complimented him on Bulletin Number Four and asked
him, "What would you do if you had a miUion dollars with which
to make a start in reorganizing medical education in the United
States?"

"Without a moment's hesitation" Flexner recommended
giving it all to Welch and the Johns Hopkins medical school.
Flexner could not have recommended anyone in medicine more
dear to Gates' heart. Gates asked Flexner to obtain a leave for a
few weeks from the Carnegie Foundation to go to Baltimore as an
agent of the General Education Board and report back on his
findings at Johns Hopkins. Flexner was delighted and went off to
Baltimore assured that the million dollars was available. ^"^

In Baltimore Flexner went directly to Welch and explained
that the GEB might add a million dollars to the Johns Hopkins
medical school endowment and that he was there to study the
situation and report back to Gates. Welch arranged a dinner that
night at the Maryland Club and invited two of Hopkins' most
illustrious medical faculty, Franklin P. Mall, an anatomist who in
effect represented the medical science faculty, and William S.
Halsted, a surgeon and de facto representative of the cHnical
faculty.

Mall spoke without hesitation: "If the school could get a sum
of approximately $1 million, in my judgment there is only one
thing that we ought to do with it — use every penny of its income

Reforming Medical Education I 157

for the purpose of placing upon a salary basis the heads and
assistants in the leading clinical departments." That, Mall added,
"is the great reform which needs now to be carried through.""

Mall's suggestion was the focus of Flexner's report to Gates.
Flexner recommended a grant of $1.5 million to reorganize the
medical, surgical, obstetrical, and pediatric departments, placing
the clinical faculty on a full-time basis. The "full-time plan"
would require the clinical faculty, at that time earning roughly
$20,000 to $35,000 a year from consultations, to become salaried
employees of the medical school and to turn over all their
consultation fees to the school. Incomes would thus drop to
$10,000 for a department head, still a very high salary for the
period, and $2,500 for his assistants.

Flexner's report, in the same tradition of thoroughness as his
Bulletin Number Four and Gates' own reports to Rockefeller
nearly two decades earlier, greatly impressed Gates. The recom-
mendation was informally adopted as policy, and, at Gates'
request, Flexner returned to Baltimore and personally explained
it to Welch and gave him an informal and confidential assurance
that a Hopkins application for $1.5 million to institute the
reforms would be approved by the GEB. It would be up to Welch
to convince his faculty and the university trustees to make the
reform, for it was to be the only basis of the GEB's grant. "No
pressure was used," Flexner recalled, "no inducement was held
out." Just $1.5 million. ^^

When Flexner brought the proposal to the GEB, the full-time
plan already had a powerful advocate within the board. Three
years earlier Gates had been instrumental in establishing the
strict full-time provision for physician-researchers at the Rocke-
feller Institute's new hospital.^'' With a view to the needs of
maintaining and further developing capitalist society. Gates
believed the full-time plan would encourage the application of
science to medicine and reduce the independence of the medical
profession.

Gates, a director of industry, finance, and philanthropy,
believed, as did other men in his position, in the usefulness of
science and technology. Science could discover the causes of
diseases, and technology could develop the means to prevent or
cure disease. But medical science could neither relieve the misery
of the world nor make the work force healthier if people could

158 I Reforming Medical Education

not afford its services. Likewise, the cultural and legitimizing
functions of medicine could not be performed if medical services
were priced out of the reach of the working population. The
financial independence of the medical profession was an obstacle
to bringing the benefits of science to the people. "This practice of
fixing his own price granted to American physicians by custom,"
Gates wrote to the other GEB trustees, "is the greatest present
American obstruction to the usefulness of the science of medi-
cine. For it confines the benefits of the science too largely to the
rich, when it is the rightful inheritance of all the people aUke, and
the public health requires they have it."^*

Commercialism was fine in the economic sectors that should
be reserved for profit making, but in medicine it violated the
needs of capitahst society. The full-time plan was adopted by the
GEB as its central policy in medical education to help bring the
medical profession to heel and subordinate its practices to the
needs of industrial capitalism for fully accessible medical care, or,
as board member Jerome D. Greene put it, to abate "commer-
ciaHsm in the medical profession. "^^ If the elite, standard-setting
medical schools supported by the GEB adopted the fixed-price
schedule for medical services. Gates argued, "public sentiment,
in no time, will enforce those schedules, if reasonable, not only
throughout their cities but other cities and finally the country at
large. "'«

The full-time plan played a central role in foundation funding
of medical education for the following important decade of
development. The new arrangement altered the relationship of
the medical profession to university medical schools. And it
caused deep divisions between the reform-minded elite practi-
tioners in the medical societies and the Rockefeller philanthro-
pies.

FULL TIME: "GOLD OR GLORY"

As Flexner himself has pointed out, the full-time plan for
clinical faculty was suggested to him by Mall, though it had first
been advocated publicly in 1902 by Lewellys F. Barker, a former
colleague of Mall's at Baltimore and then a professor of anatomy
at Chicago.''^ The earlier origins of the idea can be traced to more
obscure beginnings in German medical laboratories, but its
introduction to the United States is of interest here.

Reforming Medical Education I 159

The full-time plan was first instituted in the United States in
1893 when the Johns Hopkins medical school opened its doors.
Because of the new school's emphasis on research and the
widespread experience that local practitioners do little research in
the laboratory sciences, the university provided full-time faculty
positions in anatomy, physiology, pathology, and pharmacology.
The models for the Hopkins reform were the German medical
laboratories and universities where Welch and the other Hopkins
medical faculty got their scientific training. For some of the new
faculty who had previously spHt their time between private
practice and teaching laboratory sciences, the Hopkins plan
meant giving up an income of $10,000 a year or more, in return
for a salary of $3,000 or $4,000. But the bright young men who
were actively recruited were, like Welch and Mall, struggling to
survive without private practice. ^^ For these men, medicine was
science and laboratories, not patients and housecalls.

Welch himself had never wanted to be a physician. After
graduation from Yale, he wanted to be a tutor in Greek, but the
prospect of unemployment thwarted his ambition and drove him
to follow his father into medicine. His interest in medicine soon
bloomed though not with visions of a bedside practice. Welch was
"fired in the dissecting and autopsy rooms with the desire to
become a professor of pathological anatomy," wrote Simon
Flexner, "to study and examine for the rest of his life without
having to make his living as a practitioner." The development of
scientific medicine in the United States opened to Welch the
possibility of a new kind of medical career, and he ambitiously set
about building a future for himself in the medical sciences.
Returning from his postgraduate medical studies in Europe,
Welch, with a little financial help from his friends, founded the
first pathology laboratory in the United States at Bellevue
Hospital medical school in New York. From there he was invited
to Johns Hopkins by president Gilman as one of the first full-time
faculty in the laboratory medical sciences and was soon made
dean of the distinguished medical school. Welch devoted his life
to building the first medical center "empire," seeking favor with
philanthropists, initiating reforms in medical education and
research, and planning and organizing new programs and institu-
tions.''^

Franklin Paine Mall, after receiving his medical degree from
the University of Michigan in 1883, went to Germany for

160 I Reforming Medical Education

additional clinical training and came back a dedicated medical
scientist. In Ludwig's and other laboratories Mall learned to love
science and to appreciate the freedom to study what interested
him. In his anatomy laboratory at Johns Hopkins, Mall was an
efficient and organized administrator. He knew the investments
of all the major universities and foundations and was good at
bringing research grants to his laboratory. Mall put great value on
original research as part of the training of physicians. If disserta-
tions were required for the M.D. degree, he urged hopefully, "it
would stimulate scientific work in the medical schools, would
tend to reduce the number of graduates, and would improve the
quahty of the physician."''^

It was Ludwig in Germany who put the bug about full-time
clinical teaching into Mall's ear. Mall brought it back to Balti-
more and Chicago and spread the idea among Barker and other
colleagues. Mall saw the struggle over the full-time plan as a
contest between the clinical faculty and practicing physicians, on
the one hand, and the laboratory science faculty, on the other.
Reform practitioners had demanded full-time laboratory faculty
for the first two years of basic science in medical school, and now
"it falls to us to demand of the last two years of medicine what
they demanded of the first two." With a sense of victory
occasioned by the GEB's proposal to Hopkins, Mall added that
"the day of reckoning is at hand." The lesser salaries of full-time
faculty should not deter brilliant men and women from entering
the field. As Mall liked to put the issue, a physician must choose
"which 'G' to worship — Gold or Glory."

Other laboratory science faculty had similar motivations.
Many were undoubtedly drawn to the medical sciences partly by
the field's growing prestige, partly by their interest in the
single-minded pursuit possible in a laboratory, and partly for
escape from hustling patients and dealing with the mundane
business of medical practice.

To the laboratory scientists, limiting clinicians to their salaries
would accomplish several things at once. First, they believed that
medicine should be fundamentally a science devoted to finding
the bio-physical causes of disease and less an art of bedside
diagnosis and hopeful therapies. Second, since the medical
sciences prospered most with faculty devoting themselves entirely
to research and teaching, it followed in their thinking that clinical

Reforming Medical Education I 161

instruction would also benefit from the clinical faculty's singular
devotion to research and teaching. Third, since the medical
school competed with the clinicians' private practice for their
time and energy, eliminating private practice would unify and
rationalize the organization of the medical school. CHnicians
would no longer be responsible to an outside practice. Finally,
eliminating clinicians' private practices would unify the material
interests of all the faculty in the medical school. Clinical faculty,
leaving behind large and fashionable private practices, would
derive their incomes and reputations from the same source as the
laboratory faculty. From at least the days of Benjamin Rush,
practitioners had used their faculty positions in medical schools to
build large, prestigious, and very lucrative private practices. The
proposed full-time plan would reduce such practices, making the
main clinical faculty captives of the medical school, with loyalties
no longer divided between personally lucrative consultations and
the needs of the school for research and teaching.

Some practitioners as well as academic doctors were mindful
of the need for faculty who would commit themselves mainly to
teaching. As early as 1900, the AMA Journal argued that clinical
departments should be headed by physicians "who are properly
paid and of whom more may be demanded than of those who
regard their clinical services merely as a means of rapidly
acquiring a large private clientele. "^^

But as news of the Hopkins plan spread, the outrage among
private practitioners grew. The AMA appointed a special com-
mittee on the reorganization of clinical teaching. Its chairman,
Victor Vaughan of Michigan, tried to steer a middle course,
rejecting extreme involvement in private practice by clinical
faculty while expressing the committee's considerable skepticism
of the full-time plan. Vaughan concluded that even if the plan
were ideal, it would not be feasible for any but a few medical
schools that were well endowed. ^^

Many clinical faculty charged that full-time medical school
faculty, based in laboratories and wards, made "poor practition-
ers" because they were more concerned with research than with
patients as suffering human beings. They claimed that without a
private practice a physician would lose touch with the real
practice of medicine and be a poor example for medical students.
WiUiam Osier, the renowned professor of medicine at Hopkins

162 I Reforming Medical Education

who had introduced a number of reforms in clinical teaching, had
always been an advocate of "medicine as art" as well as science.
He frequently argued with Mall, who conceived of medicine as
simply a research science. When Osier left Hopkins for Oxford in
1904, he bitterly conceded to Mall, "Now I go, and you have your
way."''^ The initiation of the full-time plan at Hopkins must not
have surprised him, and he wrote from England his severe
criticisms of the proposed change. Similarly, the highly regarded
Society of Chnical Surgery, including such celebrated surgeons as
Charles Mayo and George W. Crile, registered their opposition
to the plan. Other general and specialty societies joined the
chorus.''^

Practitioner attacks on the full-time plan exposed their
ideological, material, and political differences with academic
physicians, particularly the laboratory scientists. Although the
practitioners' and academics' common interest in promoting
scientific medicine had united them at the end of the nineteenth
century, differences quickly developed as to just what that meant.
Academics differed with practitioners over the relative weight of
science and art in medicine, the financial interests of practi-
tioner-clinicians, and who should control medicine.

Medical scientists and their foundation alHes believed that
medicine was at its best as an exact science, isolating variables in
the laboratory and finding a cure under very precise laboratory
conditions. Practitioners, in the business of selling cures to
patients, seldom saw the relevance of laboratory controls to
treating individuals in the real world. With all their deficiencies,
the proprietary schools had, in the words of Rosemary Stevens,
"at least been firmly attuned to the average practitioner."^^ The
medical ideology implicit in the full-time plan was now driving
practitioners and academics apart.

Whether the practitioners were driven more by their commit-
ment to practice or by consideration for their bank accounts is, of
course, a moot question. The issues were so intertwined that it
was never clear whether the argument that medicine is an art was
simply a ruse to hide pecuniary motives. Clinicians fiercely
defended their material interests against the infringements of the
full-time plan. Arthur Dean Bevan denounced the plan as
"unethical and illegal" because it deprived clinical faculty of their
fees.^°

Finally, the full-time plan exposed a poHtical conflict that

Reforming Medical Education I 163

grew out of the different material conditions of practitioners and
academics. The AM A sought to control medical education as a
vehicle for controlling entry into the profession and thereby
medical care itself. The scientific medical school faculty, on the
other hand, thought that they should control medical care.
Medical scientists, remarked a prominent British physiologist in
1914, ought to "remodel the whole system so as to fight disease at
its source. . . . Surely it is a time when those who have laid the
scientific foundations for the new advances should take counsel
together, assume some generalship, and show how the combat is
to be waged. "^' The Rockefeller philanthropists clearly sided
with the medical scientists and cast their weighty fortune with the
armies of academe.

Behind the passion of the AMA's attacks were the realiza-
tions that the position of medical faculty would no longer be a
lucrative supplement for private practitioners and that the
full-time clinical faculties' main loyalties would be to medical
schools and not the organized profession. Elite practitioners
would now have to choose either a grand income or a respected
teaching and research position. But even more important to the
strategy for controlhng medical education, the full-time plan, by
reducing the clinician's income and monopolizing his loyalties
and material interests in the medical school, would cut the clinical
faculty off from private practitioners. Instead of linking together
the interests of the ehte practitioners with those of the medical
schools, full-time clinical faculty would help separate the medical
schools from the organized private practice profession. The
full-time plan would reduce the power of the organized profes-
sion, in particular, the AMA and its Council on Medical Edu-
cation, within the medical schools.

Of course, things were different in the 1910s from the way
they had been at the turn of the century. The profession's reform
strategy had accomplished much of what it set out to do: It had
established scientific medicine as the ascending model of medical
practice and education; it had reduced the number of schools
considerably and thereby the output of new physicians; and it had
secured supportive legislation and licensing laws. But the plan
had just begun to work, physicians' incomes and prestige were
rising, and the end was not in sight. Medical schools were still
considered key to the strategy and to continued control by the
organized profession of its own material conditions. And the

164 I Reforming Medical Education

AMA leadership was not about to let that control slip from its
grasp. The profession launched a campaign to discredit and
oppose the full-time plan.

SELLING THE FULL-TIME PROPOSAL

Welch, an astute medical politician, anticipated the furor the
plan would provoke. Four years before Mall suggested the idea to
Flexner, Welch had called for reforms that would allow clinical
department heads to "devote their main energies and time" to
teaching and research, "without the necessity of seeking their
livelihoods in a busy outside practice and without allowing such
practice to become their c/z/^/ professional occupation. "^^

When the GEB proposed to fund full-time organization of
Hopkins' clinical departments, Welch faced the dilemma of medi-
ating the interests of the laboratory science faculty with those
of the clinicians. Welch asked the GEB to allow some excep-
tions to the full-time rule, enabling the university president or
"some other responsible authority" to permit some full-time,
salaried professors to keep their consulting fees.*^ The board
adamantly refused to allow any exceptions.

The laboratory faculty unanimously endorsed the plan, but,
Flexner later recalled, "there was a rift among the clinicians. "^"^
Within two years Welch won sufficient support from the clinical
faculty. Lewellys Barker, the Hopkins professor of medicine who
had publicly advocated the full-time plan in 1902, stood in the
way of its implementation at Johns Hopkins. He chose "gold"
over "glory" and resigned his professorship, agreeing to become
a "clinical professor," drawing a small salary from the medical
school but being able to devote most of his time to a lucrative
private practice. In his place, Theodore Janeway gave up his chair
at the College of Physicians and Surgeons and an elite practice in
New York to become the first full-time professor of medicine in
the United States. William Halsted was named professor of
surgery and Charles Howland, professor of pediatrics. In October
1913 Welch formally applied for the grant, accepting the condi-
tion that the full-time clinical faculty at all ranks — assistant
professor to professor — would "derive no pecuniary benefit"
from any professional services they rendered. The board immedi-
ately voted its approval and a grant of $1.5 million. ^^

Reforming Medical Education I 165

Three months later the GEB decided to devote all its funds in
medical education to "the installation of full-time clinical teach-
ing." Flexner had been hired by the board to administer their
program in medical education, and he applied himself with his
usual energy/^

Within a year Welch reported that "the full-time system is a
great success" at Hopkins.^'' Halsted and Rowland found the
system to their liking, but Janeway resigned his position in 1917
to return to private practice in New York. He was dissatisfied
with the full-time arrangements, he wrote in a widely publicized
journal article, both because "outside engagements" had been a
major source of clinical knowledge to him and because he and his
family were used to a higher standard of living than he could
afford on his salary. It was "unnatural and repugnant to the
patient's sense of justice," he said with great sympathy for his
patients, "that a consulting physician should not receive the usual
fee for such service."*^

In 1919 even Osier backed off from his opposition. He asked
Welch to use his influence to persuade the GEB to "help McGill
start up-to-date clinics in medicine and surgery." Osier made it
clear that he did not favor the full-time scheme, but he believed it
was now necessary at the Canadian school because "new condi-
tions have arisen" which would leave McGill behind the other
first-class schools that had instituted full-time teaching in medi-
cine and surgery.*^

Over the next few years the board voted more than $8 milhon
from its general funds for similar reorganizations on a full-time
basis of the medical schools at Washington University at St.
Louis, Yale, and the University of Chicago. With the matching
grant policy, these funds represented several millions more in
support for the reforms. Between 1919 and 1921 Rockefeller, Sr.,
contributed $45 million to the General Education Board specifi-
cally for medical education.

The first appropriation from this special fund was a grant of $4
million to Vanderbilt University to make the Nashville medical
school a model for the South. The GEB considered Nashville its
"strategic point" in the South and Vanderbilt the institution that
would lead the drive to improve Southern "public health and
industrial and agricultural efficiency. "^° By 1960 Vanderbilt, the
board's major white university in the South, received a total of
$17.5 million from the GEB for medical education. Meharry

166 I Reforming Medical Education

Medical College, the board's model black medical school and one
of only two that Flexner had argued should survive, received less
than half the sum given to the white institution.^' Despite its
relative stinginess toward black medical education, the board
firmly believed that scientifically trained black doctors were
necessary to improve the health of blacks, protect the health of
neighboring whites, and provide an elite and "responsible"
leadership for the black population. Through its annual grants to
Meharry, it exerted substantial control and even instituted
full-time teaching in medicine and surgery in the 1930s, with
approved white faculty members in charge and a hand-picked
white president. ^^

The board used its $45 million to foster, if not force,
acceptance of the full-time plan at the major medical schools in
the country. But not all the schools were won over as easily as
Hopkins.

BOSTON BRAHMINS RESIST

Harvard staunchly refused to accept the full-time plan. In
1913, while negotiating the details of the Hopkins grant with
Welch, the GEB invited the Harvard medical school to apply for
a grant to place their cHnical departments on a full-time basis.
The debt-ridden medical school sought a windfall through sub-
terfuge. The faculty asked for $1.5 milHon to reorganize all its
cHnical departments "on a satisfactory university basis." The clin-
ical professors would "devote the major part of their time to
school and hospital work," but they could still collect fees from
their private patients whom they would see in offices provided by
the teaching hospital. This proposal was hardly consistent with
the GEB's by then well-known interpretation of full time.'^

The opposition to the GEB's strict full-time policy was led by
two powerful members of the Harvard clinical faculty, Harvey
Gushing, a renowned neurosurgeon and chief-of-surgery at Peter
Bent Brigham Hospital (a Harvard teaching hospital), and Henry
A. Christian, former dean of the medical school. Gushing and
Christian, like other members of Harvard's clinical faculty, had
lucrative private practices, which they refused to give up. They
felt it was enough for the clinical faculty to devote themselves to
working in the teaching hospital and "to confine their profession-

Reforming Medical Education I 167

al activities within its walls." In return, they wanted to accept fees
from "patients who might consult us during hours as we felt
justified in setting aside for this purpose." Committed though he
was to academic medicine, Gushing even offered his resignation
to Harvard president Lowell. But, as Gushing undoubtedly knew,
Lowell considered the famous surgeon more important to
Harvard's academic reputation than the $1.5 million endow-
ment.^^

Gates and Flexner continued to press for strict full-time
commitments, turning down Harvard's proposals during several
years of negotiations. In addition to their ideological commitment
to full time, the GEB members had a pragmatic incentive for
pushing it as quickly and widely as possible. Harvard and other
schools that allowed their medical faculty to keep their consulting
fees were raiding the faculties of schools that adhered to the
GEB's policy. In 1921 David Edsall, dean of the Harvard medical
school, tried to lure Gharles Howland, the Johns Hopkins
pediatrician, with the same salary he was getting at Hopkins /?/i/5
consulting fees from private practice. Flexner had to help
Hopkins upgrade their facilities as an inducement to keep
Howland there. ^^

Harvard was able to resist the full-time plan because of its
reputation as a leading scientific medical school and because its
clinical faculty were too prominent in Boston's ruling social
circles to be easily dismissed. Already by 1900 the Harvard
medical faculty boasted that it controlled "probably more clinical
material than any other one school in the country. "^^ Such
powerful medical figures were also physicians to the Boston
upper class, and by virtue of their earnings, and many their
births, they were themselves members of that very class-con-
scious city's upper crust. It took such Brahmins to refuse to
surrender their consulting fees in the face of the GEB's compel-
Hng offer, particularly when the school's accounts were heavily in
the red.

FEAR AND TREMBLING IN THE BOARD ROOM

Meanwhile, Gharles Eliot, the illustrious former president of
Harvard and a trustee of the GEB, carried the battle into the
GEB's board room. Eliot argued that "great improvements in

168 I Reforming Medical Education

medical treatment have in recent years proceeded from men who
were in private practice. "^^ EHot went on to argue not merely for
Harvard's latest proposal but for a complete reversal of the
full-time policy and the binding contracts imposed by the GEB on
universities accepting its beneficence. How could the insistence of
the GEB on full time be reconciled with the board's theoretical
hands-off policy, he asked rhetorically. Eliot reminded the board
that it had pledged itself not to interfere with the running of a
recipient institution, "except as regards its prudential financial
management." Yet the board was making its strict interpretation
of full-time clinical organization the condition of a grant. "This
condition does not seem to me consistent with what I have always
believed the wise and generally acceptable policy of the board,"
Eliot diplomatically concluded. ^^

Eliot's arguments fell on receptive ears. The Rockefeller
philanthropies were under fire from a range of groups, individu-
als, and newspapers spanning a considerable portion of the
contemporary political spectrum. Ida Tarbell provided fuel for
roasting John D. Rockefeller and his financial empire with her
"History of the Standard Oil Company," published from 1902
to 1904 in McClure's Magazine. In the latter year, Theodore
Roosevelt was elected President on a platform of vacuous
promises to bring the trusts to heel. Encouraged by growing
popular resentment against the "robber barons" and wishing to
channel that resentment through stable political institutions, the
Progressive movement won support from the courts as well as the
Congress for small reforms and slaps on the wrists of the largest
trusts. In 1907 federal Judge Kenesaw Mountain Landis struck
Standard Oil of Indiana with an unprecedented $29 million fine
for receiving rebates from the Chicago and Alton Railroad.
Making its way through the courts was an unprecedented
anti-trust suit. On May 15, 1911, the Supreme Court ordered the
Standard Oil Trust, then controlling nearly 90 percent of oil
refining and sales in the United States, broken up. Neither action
slew the Standard Oil empire nor diminished the fortune of John
D. Rockefeller and his family. But as part of a growing public
attack on Rockefeller and on unrestricted capital accumulation,
these attacks were taken seriously by the Rockefellers and their
industrial, financial, and philanthropic organizations.

Hoping to calm the troubled waters of popular hostihty and to

Reforming Medical Education I 169

fuel his engine of social transformation, the Standard Oil
billionaire attempted to get a congressional charter for the new
Rockefeller Foundation. The proposed charter sparked a verita-
ble firestorm of protest from working-class and Progressive
leaders and newspapers. The Los Angeles Record denounced the
"gigantic philanthropy by which old Rockefeller expects to
squeeze himself, his son, his stall-fed collegians and their camels,
laden with tainted money, through 'the eye of the needle.' "
Expressing a widespread suspicion of philanthropy, the paper
argued that the "monopoly-ridden masses don't want charity
under any guise, but justice." The charter bill foundered in
Congress for three years and in the end failed to sweep aside the
articulated public anger. ^^

The Rockefeller organization found a more receptive mood in
Albany and was granted an unrestricted charter by the New York
legislature in 1913. But even in New York, anti-Rockefeller
Progressive sentiments continued to haunt both the man and his
corporate philanthropies. In 1917 State Senator John Boylan
introduced a bill to repeal the foundation's charter. Although this
attack also failed to stop the Rockefeller philanthropy, it added
flack to the assault. What most upset the Rockefeller group about
this campaign were the testimony and speeches in support of the
bill from Bird S. Coler, a respected Wall Street stockbroker
cum-Progressive . ^ °"

Meanwhile, more specific attacks were being leveled against
the Rockefeller and Carnegie foundation programs. The National
Education Association (NEA), meeting in St. Paul in 1914,
condemned the foundations' education programs for introducing
undemocratic controls into the schools. Working-class and Pro-
gressive newspapers supported the NEA resolution. The radical
organs understood the capitalist class character of the foundation
programs in education. The Pittsburgh, Penn., Leader considered
the foundation programs so effective "that it is difficult for
genuine teachers to make any headway against the class concepts
that hold their heads so high in school and college. "*°^

The most thoroughgoing indictment, however, followed the
"Ludlow Massacre" at the Rockefeller-controlled Colorado Fuel
and Iron Company. When workers at the mining operation went
on strike in 1914 for union recognition, an eight-hour day, and
emancipation from the choking economic, political, and social

170 I Reforming Medical Education

control of the company over the Ludlow miners and their
families, the company brought in armed guards. On April 20 the
company's private army together with the state militia shot to
death six workers and burned the tents in which the strikers'
families were forced to live, cremating two women and eleven
children inside them. The Ludlow Massacre shocked an already
aroused public and focused anger against the Rockefellers. Labor
unions, anarchists, socialists, and radicals organized demonstra-
tions and demanded broad reforms to protect labor. Progressives
joined the cry for action, and even conservative newspapers
criticized the mining company.

Congress created, and President Wilson appointed, the Com-
mission on Industrial Relations to investigate the Ludlow affair,
relations between capital and labor, and the role of philan-
thropic foundations in general. The commission, headed by Frank
Walsh, exposed much of capital's relations with the working
class to examination and criticism and pointed to the impor-
tant role of foundations in building a superstructure to extend
capital's control throughout society. The Walsh Commission
subpoenaed the senior and junior Rockefellers, Charles W.
Eliot, and Jerome D. Greene to testify about the activities of the
Rockefeller Foundation. The commission's final report noted
that the Rockefeller and Carnegie foundations' policies are
"colored, if not controlled, to conform to the policies" of the
country's major corporations, which are themselves controlled by
a "small number of wealthy and powerful financiers. "^°^

The attacks on Standard Oil and on unrestricted capital ac-
cumulation, the hostility to foundations and the Rockefeller
programs in particular, and the increased support for radical and
socialist working-class movements greatly impressed the rrien of
the Rockefeller philanthropies. Eugene Debs, a revolutionary
socialist, rolled up nearly one million votes for President in 1912.
In the Rockefeller offices and board rooms at 61 Broadway, the
din outside must have sounded at times like the trumpets of
Jericho.

General Education Board member George Foster Peabody, a
New York banker, feared the rising tide would force the gov-
ernment to assume all support of educational institutions
(robbing the foundations of their power and influence) and would
also lead to "economic legislation which shall preclude the

Reforming Medical Education I 171

acquisition of surplus wealth" (the end of capitalism itself).
Peabody preached caution in the face of such challenges. '^^

Charles Eliot feared the outcome of class conflicts, but he
believed the best defense were the programs the foundation had
already undertaken:

We need not imagine that the process of accumulating great
fortunes ... is going to continue through the coming generations.
. . . The evils which I look forward to with dread in the coming
years of the Republic are injustice inflicted on those who have by
those who have not, and corruption and extravagance in the
expenditure of money raised by taxation. Against such evils I know
no defense except universal education including the constant
inculcation of justice and goodwill. ^°'*

Gates himself feared possible "confiscation" of wealth, but he
had faith in the strength of capitalism to survive. "The recogni-
tion of the right to earn and hold surplus wealth marks the dawn
of civilization," he noted to himself in 1911.^°^

Gates favored standing fast on the principle of private control
of wealth and opposed any special defensive strategies. When
Rockefeller Foundation president George Vincent drafted the
annual report for 1917, Gates suggested removing a new self-
limiting policy statement. Among other points, the new pohcy
precluded the foundation from "supporting propaganda which
seek to influence public opinion about the social order and
political proposals." Vincent defended the statement on the
ground that "the one thing that the opponents of foundations
seem most to resent is that attempt to control public opinion. "^''^
It was hoped that the formal statement denying the charges would
be accepted by the public as a verdict of innocence.

FEAR UNDERMINES THE FULL-TIME POLICY

Board members feared that the full-time contracts would be
seen by the public as another example of private capitalist control
of essentially public institutions. Visions of more public attacks
and restrictive legislation undermined support for the full-time
policy within the board. Anson Phelps Stokes, who succeeded
Peabody on the board as the voice of caution, counseled against
imposing the full-time policy through contracts. "It is not a
question of whether we are right or wrong in our opinions," he

172 I Reforming Medical Education

explained. The full-time plan itself was not an issue. In fact, he
thought it was a commendable program.

But it is a question of whether or not we can . . . afford — in view of
public opinion and our great wealth as a board — to be imposing, or
at least requiring, detailed conditions regarding educational policy
in medicine in elaborate contracts which can only be amended with
our consent. . . . Personally, I think this policy unwise and fraught
with serious dangers.'^

107

The "elaborate contracts" were a policy brought by Gates
from the American Baptist Education Society to the Rockefeller
business dealings and philanthropies. Applied by the GEB to
their grants to medical schools, contracts with the recipient
universities uniformly included a clause specifying that if the
full-time plan "shall, without the consent of the said General
Education board, be abandoned, substantially modified or de-
parted from, the said university will, upon demand of said
board, return said securities or any securities representing their
reinvestment. "^°*

Stokes' fear that the contracts would become public knowl-
edge was prophetic. While Eliot, Lowell, and the medical faculty
at Harvard could be counted on to keep a gentlemanly silence
about their conflict with the GEB, the more volatile president of
Columbia, Nicholas Murray Butler, was not adverse to spiUing
the beans. Under Flexner's hard-nosed leadership, the GEB
offered Columbia a substantial grant but only if the university
took more decisive control of the medical school, booted out the
reigning dean and clinical faculty while instituting the full-time
policy, reduced the student enrollment in the medical school, and
took more complete control of Presbyterian Hospital as a
teaching facility. '°^

After lengthy negotiations between Butler, Flexner, and
representatives of the Presbyterian Hospital trustees, Butler
rejected the proposals as "so reactionary and so antagonistic to
the best interests of the public, of medical education and of
Columbia University, that they will not, under any circumstanc-
es, be approved by us."^'''

The Presbyterian Hospital trustees, led by philanthropists
Edward S. Harkness, W. Sloan, and H. W. deForest, had favored
creating a new medical center and had supported all the con-
ditions the GEB was demanding. In 1911 Harkness had given

Reforming Medical Education I 173

Presbyterian Hospital $1.3 million to encourage them to tighten
their bonds with Columbia, giving the medical school exclusive
teaching privileges in the hospital and control over Presbyterian's
medical staff/" Angered at Butler's rejection of the proposals
and his support for the existing practitioner faculty, the hospital
trustees voted to sever all ties with the Columbia medical
school."^

Negotiations continued, with Henry Pritchett and the Carne-
gie Foundation entering the fray in 1919. The Carnegie Founda-
tion joined with the GEB and the Rockefeller Foundation to
offer $1 million each toward building a new medical center for
Columbia and endowing its faculty. Yet the GEB held out for
complete fulfillment of their policy on full time."^

Pritchett could see no reason for such obstinacy. "It is quite
true," he told Flexner, "that certain of the professors are allowed
to take a small consulting practice. . . . That is not 100 percent
fulfillment, but I should say that it was comparable to the claims
of Ivory Soap to be 99.44 percent pure."""*

Pritchett was not only uncommitted to complete subordina-
tion of the medical faculty through a strict full-time policy. He
also, and perhaps more viscerally, feared attacks on the founda-
tions and the recipient universities. "Such a contract binding a
university to a fixed policy laid down by the giver of money seems
to me a dangerous thing," he complained to Wallace Buttrick,
president of the GEB. "If these contracts were made public, I am
sure it would bring down on all educational foundations no less
than on the universities themselves severe criticism. It seems to
me a dangerous poHcy for those who administer trust funds to
adopt. ""^

The standard response of the GEB officers to such criticisms
of their full-time plan contracts was that "the policy was proposed
to us by the trustees and medical faculty of the university and that
the terms of the contract were such as they themselves asked
for.""^ According to this fiction, it was Welch who proposed the
full-time plan to the GEB. "We have never asked any institution
to adopt the plan," Buttrick claimed. "The Hopkins proposal in
all particulars came from Doctor Welch.""'' This self-serving
posture was supported by carefully worded statements in letters,
personal contacts, and even the contracts themselves. Flexner
and others orally and confidentially made known the board's
requirements, and they were always careful that any written

174 I Reforming Medical Education

proposals came from the institution. The painstaking, almost
nit-picking negotiations with the Columbia medical school facul-
ty, Columbia's president Butler, and trustees of the university
belie the GEB's claims that it had "no fixed policy regarding
medical education" and that they never attempted to influence
the internal policies of universities.^'*

After continued resistance by Harvard and Columbia, public
disclosure of the binding contracts, public criticism by the medical
profession, and a long history of attacks on corporate philanthro-
py, the board in 1925 altered its contracts and thus its full-time
policy. Eliot had continued his attacks within the board meetings
right up to the time of his resignation in 1917, charging the GEE
with interfering in the internal affairs of Harvard by demanding
full-time organization as the price of an endowment grant. Board
member Anson Phelps Stokes carried on the fight to do away with
binding contracts and the GEB's narrow definition of full time."^

WINDOW dressing: gates defeated

Although the public clamor for aboHtion of foundations, or at
least for their severe restriction, had abated with the demise of
Progressivism, the entry of the United States in the Great War,
and the repression of radical and socialist movements following
the war, a majority of the GEB's trustees feared a resurgence of
such attacks. "Some day the power of the 'dead hand' will again
be the subject of poHtical, if not popular, discussion," warned
Thomas Debevoise, legal counsel to the board. '^°

Debevoise prepared the arguments to support the majority of
the trustees in their fight with Flexner and Gates. First, it was
important for the board not to appear to control recipient
institutions. "It will hurt the reputation of the board if it attempts
to direct the operation of the objects of its bounty," Debevoise
argued. Second, binding contracts were unnecessary to keep the
universities in line. "Most of the schools which receive money
from the board come back at least a second time, and the
possibiHty of their needing additional help should lend all the
inducement necessary to make them follow the ideas of the
board."'^'

On February 26, 1925, the board voted, with Gates adamantly
dissenting, to authorize a contract with the University of Chicago
that required full-time clinical faculty to receive no fees for

Reforming Medical Education I 175

patients seen in the university's teaching hospitals but allowed
them to "continue to engage in the private practice of their
professions outside of the university's hospitals." The contract
also allowed the university's board of trustees to make ''such
modifications and changes by the university in future years as
educational and scientific experience may . . . justify. "'^^

The final defeat for Gates and Flexner came later that year.
At the end of September the executive committee of the GEB
voted to modify the original contracts with Johns Hopkins,
Vanderbilt, Washington (at St. Louis), and Yale universities to
allow the boards of trustees to compromise the full-time provision
(if they desired). Gates specifically asked to have his negative
vote recorded.'" Gates took his defeat at age seventy-two as a
personal attack and a political blunder. Actually, the policy
change was a minor one, a question of tactics rather than of
strategy.

The full-time plan was an entering wedge, the first thrust of a
continuing struggle by corporate philanthropy to control medical
education and medical care — to establish the principle that
society's needs, as defined by the corporate class, would prevail
over the medical profession's interests. It was the first attempt on
a large scale to rationalize medical care in the United States.
Gates saw clearly the potential value of academic medicine —
doctors subordinated to the university, the university controlled
by men and women of wealth, and academic physicians research-
ing the causes of disease and eliminating those causes at their
microbiological source. All these relationships and functions
would assure that academic doctors, unHke their practitioner
colleagues, would serve the needs set before them and not some
competing professional interest.

But in 1925 Gates was a strategist from another era. Although
a loyal manager himself, he was a product of early corporate
capitalism's rugged individualism, who never adapted to corpo-
rate liberalism's trust in the State and other bureaucratic organi-
zations run by professionals and managers. He did not realize
how fully academic medicine was already the instrument of
foundation and capitalist interests.

Dependent on outside funding for its capital and operating
expenses, medical education could be guided by whoever footed
the bill. The GEB and Rockefeller Foundation efforts to insti-

77^ / Reforming Medical Education

tutionalize full-time clinical departments had their efiect, even
with the resistance and the final defeat of binding contracts. Of
the $13 million in medical school operating expenses in 1926, the
largest chunk — 42 percent — went to salaries of full-time fac-
ulty. The Commission on Medical Education reported that in
the twelve years since the GEB launched its program with Johns
Hopkins, the largest single increase in budgets was "for salaries
and other expenses in the clinical divisions, particularly in those
schools which have placed the clinical departments on a universi-
ty basis. "^'^

Medical colleges were caught in a bind. Dependent on student
fees, they had always been responsive to student demands. By the
turn of the century, state licensing boards were requiring at least
the rudiments of a scientific medical education. In 1907 the
secretary of the Association of American Medical Colleges was
able to report that students no longer sought merely the cheapest
route to a medical degree. Guided by the demands of state
boards, they wanted scientific medical education "and they are
willing to pay for it." Every medical college that kept step with
"the better schools" found "that the step taken was a profitable
one in every way."'"

The catch was that it took more than student fees to make
those changes. Although tuition fees increased to pay for the
changes — in 1910, 81 percent of the medical schools charged less
than $150 per year whereas in 1925, 85 percent charged more than
that in fees — they could not increase beyond the willingness of
the middle class to pay them. Nevertheless, by 1927 more than
one-third of the annual income of medical schools still came from
tuition fees. Income from endowments was, by the mid-1920s, the
second largest source of income and meant the difference, for
most medical colleges, between making it as a class A school or
not making it at all.'^^ The influence of the General Education
Board and the Rockefeller Foundation was profound.

STATE UNIVERSITIES: PROFESSIONALS,
THE STATE, AND CORPORATE LIBERALISM

Between 1919 and 1921 Rockefeller, Jr., Flexner, and Gates
persuaded the elder Rockefeller to give the General Education
Board $45 million to be used for medical education. With the

Reforming Medical Education I 177

foundation's program of building up several elite private medical
schools well underway, Flexner wanted to expand the program to
the lesser but still "strategic" schools of the West and the South.

In the East medical education is altogether in the hands of privately
endowed institutions of learning. With the exception of some eight
or ten schools, medical education in the West and South is in the
hands of state universities. The board has found it practicable to
cooperate with endowed institutions in developing their medical
schools. It has had thus far no experience with state or municipal
institutions in this field. It is evident, however, that if Mr. Rock-
efeller's benefaction is to be made generally effective, cooperation
with state and municipal universities is necessary.'"

It was not long before Flexner brought a concrete proposal to
the board to help the University of Iowa build a modern medical
center across the river from its small and outmoded facility. The
state legislature had dramatically increased its support of the
medical school from less than $70,000 in 1912-13 to more than $1
million in 1922-23. But generous though it was to the medical
school, the legislature would not appropriate the whole $4.5
million needed to build a new medical center. Assured of
continuing support by the governor and the legislature, Flexner
proposed that the Rockefeller philanthropies donate $2.5 milHon,
with the state agreeing to raise the remainder from the taxes of
the people of lowa.^^^

When Flexner brought the proposal before the board, Gates
prepared an unusually long and passionate speech. The stormy
meeting was held over two days at the Rockefeller funds' favorite
retreat, Gedney Farms near Whhe Plains. Gates orated for the
first half day, his white hair falling in disarray over his forehead,
and his necktie twisted out of place by his forceful gestures. '^^

Gates attacked the proposed grant to Iowa because: (1) it was
a state university, (2) it was therefore "controlled by the
taxpayers," (3) "the taxpayer is not intelHgent on the needs and
cost of first-class medical education," (4) no attempt was being
made "to give Iowa the one supreme and simple thing Iowa
needs — ^viz., illumination of the voter," (5) the indigenous Iowa
leadership were incapable of carrying out their ideals of uplifting
the medical school, and (6) the proposal was presented by
Flexner, whom Gates had grown to despise as an upstart, one of

178 I Reforming Medical Education

the "bureaucratic officers, usurping the power of the board. "'^°

Flexner followed Gates and presented his arguments in favor
of supporting Iowa's medical school "in the mildest manner that I
could possibly assume." He defended the plan as being practica-
ble and necessary. "We are trying to aid in the development of a
country-wide, high grade system of education in the United
States. If we confine our cooperation to endowed institutions,
we can practically operate only in the East." Flexner's brief,
low-keyed presentation suggested the demeanor of a man assured
of victory.'^'

That afternoon and the next day board members participated
in the discussion. The vote was overwhelmingly in favor of fund-
ing the Iowa proposal.

Gates never forgave Flexner's opposition. "It is amazing," he
angrily wrote Flexner. "How could you! You have never squarely
met one of my arguments." The issue of not contributing to state
universities was a sacred one to Gates. ^^^

For Gates, the issue of the board's making gifts to state
universities was bound up with his views on the relations between
capital and the State and his attitude toward the people generally.
Gates did not argue against the existence of state universities.
"Indeed, not a few advantages must be conceded them arising out
of the fact that they are tax-supported," Gates asserted. "Every
taxpayer is told by his annual tax bills that the higher education is
not less necessary for a democracy than the district school and the
high school at his door; and that all three are equally the
inheritance of his children; that the university is not a privilege
reserved for religion or leisure or wealth, but belongs equally to
every citizen.'""

Gifts from private wealth, however, would violate the "princi-
ple" of taxpayer support for state universities. They are "needless
and gratuitous" as well; in 1923 state medical schools received
fifteen times more state funds than they got in 1900, a testimonial
to the "pride which legislature and people alike take in their
universities" as well as to the threefold increase in the states'
wealth. '^^

Worse yet, gifts by the Rockefeller philanthropies to state
universities would cooperate with the state and federal govern-
ments' inheritance taxes, "designed to confiscate between them

Reforming Medical Education I 179

the whole of very large fortunes." Since the Rockefeller philan-
thropies were "the only part of the Rockefeller fortune certainly
safe," none of their funds should be "thrown into the swollen
maw of the confiscatory states. "^^^

"endow private colleges"

This attitude toward the states had been the official policy of
the GEB from 1906 until the 1919 policy statement on the need to
expand the medical education program to state-supported medi-
cal schools. The board was initially endowed by Rockefeller, Sr.,
with $1 million in 1902. In 1905 Gates and Junior persuaded the
old man to donate another $10 million to allow the board to
expand its program. Gates wrote Rockefeller's letter accompany-
ing the gift, saying the funds were to be used "to promote a
comprehensive system of higher education in the United States."
As a member of the board, Gates proceeded to define what "the
founder" intended in "his" letter and gift. Gates emphasized the
necessity of forming a rationalized system of stable colleges and
universities, "comprehensively and efficiently distributed. "^^^

Gates' plan was to build up private institutions in population
centers by providing them with substantial endowments. The
board should "cooperate with denominational agencies," which
then controlled most of the private colleges, but the colleges were
not to be aided so long as they remained creatures of any church.
All of the Rockefeller-funded colleges and universities, as with
the Carnegie Foundation's policy, were to be strictly nonsectarian
and nondenominational. In addition, Gates declared, "we must
seize the centers of wealth and population." Only they can assure
continuing support for universities and colleges, adequate student
enrollments, and a mutually supportive relationship between the
institution and the local business class. This relationship was
necessary "for influence, for usefulness, and for every form of
power. "^^"^

Finally, support by the foundation should usually take the
form of contributions to the institutions' endowments rather than
yearly appropriations for operating budgets. Gates and Rockefel-
ler learned from their experience with the University of Chicago
that supporting a college's operating expenses could easily

180 I Reforming Medical Education

become like quicksand, consuming the whole energy and fortunes
of the foundation. Moreover, Gates laid out four strategic
reasons for making endowments the prime work of the GEB/^*

First, endowments will give universities and colleges financial
stability, enabling them to attract a faculty of "great gifts and
attainments" without having to pay them high salaries. High-
calibre academicians are attracted "not for money but for
security, for permanence and continuity of work, for freedom
from distraction." The same argument, that people are drawn
into academic careers for reasons of security and the undistracted
pursuit of research, was applied a few years later to support the
demand for full-time clinical faculty. '^^

Second, by providing endowments to carefully selected
institutions, the foundation could "preserve and mass our
income ... on the strategic points in ever:increasing and cumu-
lative power." It would not be dissipated in smaller amounts on
the operating budgets of lesser programs. Third, general endow-
ments given by the GEB would call forth other gifts and personal
involvement by the local business class. ^^°

Finally, the financial stability of the colleges, the involvement
of local capitalists in them, and the continued power and wealth
of foundations like the GEB would keep the colleges and
universities out of the hands of the people. With sufficient
endowments, "no clamor of the masses can embarrass the
fearless pursuit and promulgation of truth." This truth, hke the
colleges themselves, was intended by Gates, as he quoted John
Stuart Mill, "to rear up minds and aspirations and faculties above
the herd [and] to educate the leisured classes. "^"^^

The failure of state universities is their financial dependence
on the legislature and the populace. "That fact becomes a
powerful reason for endowing the private institutions," Gates
candidly argued to the board. "If the test should ever come, the
power which will act most effectively to preserve the state
institutions will be private and denominational colleges and
universities amply endowed and holding and teaching truth
whatever may be the passions of the hour, and ultimately
directing popular opinion into right channels." And, Gates
prophesied, guiding the universities will be private foundations,
"everywhere numerous and free." They will "so enlighten and

Reforming Medical Education I 181

direct popular opinion at all times that there can never ensue a
conflict between the democracy and its state universities."^"*^

Thus, giving endowments to colleges in a system of higher
education is like planting "apple trees" in the orchard of
capitalism.

I want to see a hundred colleges in this country so planted as to
cover the whole land and leave no part destitute, each of them
planted in a fruitful soil, each so planted that it shall not be
overshadowed by others, each conducted under such auspices as will
take care of it, see that it is watered, particularly in its earlier years,
see that it is properly fertilized, see that the forces of destruction
which always fasten themselves on institutions shall be pruned
away.^"*^

A NEW ROLE FOR THE STATE

During the period in which Gates' policy against giving to
state universities was in force, the GEB, with Gates as chairman
until 1917, often contributed to state programs. The board
provided the salaries of professors of education at Southern state
universities to tour their respective states to urge development of
tax-supported high schools. The board paid the U.S. Department
of Agriculture for the expenses of agricultural demonstration
programs in the South. The campaign against the hookworm in
the South and throughout the world was conducted by state and
national health departments whose expenses were paid in part by
Rockefeller money. ^'^'^ But there were two important differences
between these programs and the issue of contributing to state
university medical schools.

First, the Rockefeller organization directly controlled all
these programs. The GEB named the professors of education and
defined their duties. Each professor toured his state "as an officer
of the university, laden with its wisdom and moral authority."
The high schools that were built because of his efforts were paid
for and supported by the state and local governments. Similarly,
the GEB found and hired Seaman Knapp to develop the
agricultural demonstration program. And, again, "the hookworm
work is done in every state under the guise of the State Health
Boards, while it is in fact minutely directed by Mr. Rockefeller's

182 I Reforming Medical Education

staff and paid for with Mr. Rockefeller's money. '""^^ Clearly,
Gates and the Rockefeller philanthropies were willing to give
money to the State when the State provided legitimating cover for
their programs and when they were able to direct the operation.

Second, higher education differed from other programs. The
bulk of Rockefeller's fortune was being used to expand the
economic base of society — "employing labor, multiplying the
means of subsistence, and enlarging the national wealth." But
Gates recognized that other elements of civilization were equally
important if the base was to survive. While Rockefeller's indus-
tries were "enlarging the national wealth," his philanthropies
must stimulate "progress in government and law, in language
and literature, in philosophy and science, in art and refinement."
And all these "are best promoted by means of the higher
education. "^"^^ Thus, the institutions that wrought progress in any
one sphere — agriculture, public schools, health — were not so
important as the institutions that promoted progress of the whole
of civilization.

Because they are so widely believed to be fundamental to
modern society, colleges and universities are more visible and
thus more difficult for a single, national private philanthropy to
control. Since the GEB and the Rockefeller Foundation could
not control the institutions directly, they had to rely on people
within each state. For Gates, it was tenuous enough to rely on
local business classes to control private colleges. It was unthink-
able to yield that control to the people, even through their
legislators. It became a sacrosanct principle for Gates not to
support state university programs that could not be directly
controlled by the foundation.

As public and governmental attacks on Rockefeller and his
philanthropies started to mount, Gates' confidence in the ability
of private colleges and foundations to protect private wealth
turned to bitter pessimism. "There are too many evidences for
my peace of mind," he wrote Rockefeller, Sr., following Judge
Landis' anti-trust decision in 1907, "that wherever the voice of
the people finds absolutely free expression, that voice is not the
voice of reason, of enhghtenment, and least of all of a deep-
seated sense of right in pubHc things." The people's voice is
merely "the voice of reckless greed to lay violent hands on other
people's property. "^'^''

Reforming Medical Education I 183

Although all the political, legal, legislative, and public opin-
ion attacks never seriously diminished Rockefeller's wealth,
they struck sufficient fear into members of the capitalist class to
make them somewhat circumspect in their actions. The GEB
members gave up binding contracts and their strict full-time plan.
But these "ominous" signs of the times made Gates all the more
rigid. He strongly opposed weakening the full-time conditions,
and he clung ever more fiercely to his view of the potential evils of
the state universities and the importance of "throwing around
them in every state a cordon of strong, free, privately endowed
colleges and universities.""^*

To Gates, then, the fight within the General Education Board
over the appropriation to the state University of Iowa's medi-
cal school was a struggle over fundamental principles. Would
Rockefeller's fortune be dissipated and, even worse, given over
to the enemy? The board answered by overturning the policy
established by Gates.

The GEB, including Rockefeller, Jr., and its newer officers
were not acting on impulse or out of fear in contributing to state
universities. They were impressed by the need to build a ra-
tionalized system of medical schools and realized that much of
the medical education in the country would necessarily fall to
state schools. Furthermore, they trusted the state universities
because they understood the strength of institutional structures
and the class ties of professionals as forces for "constructive" but
conservative social and technological change. Raymond Fosdick,
one of the new GEB members and later president of it and the
Rockefeller Foundation, explained the board's defeat of Gates'
policy: "Gates did not understand the progressive forces which,
even as he spoke, were converting the great state universities into
the social and scientific laboratories they have become.

"149

MODERNIZING THE GEB! GATES DEFEATED AGAIN

Soon after the board's decision to pursue and develop the
Iowa grant, Flexner brought in other requests to fund state-
supported medical schools. By the middle of 1921 the board
voted to aid four more taxpayer-supported medical schools — at
the universities of Cincinnati, Colorado, Georgia, and Oregon —

184 I Reforming Medical Education

that had accepted the university arrangements that prevailed at
Hopkins and the other ehte private schools. '^°

After a couple of years of ad hoc decisions, Gates insisted his
policy be respected or debated and voted on as policy. "Our
funds, and our rules of policy," he declared to the board, "form
our legacy to our successors." Exceptions "should be treated as
exceptions. It is vital that these successive boards have written
policies and the habit of them."'^^

At the end of 1924 the board voted to appointed a committee
to recommend a policy on aid to state universities. The GEB
committee consisted of Gates; Rockefeller, Jr.; George Vincent,
president of the Rockefeller Foundation; James Angell, presi-
dent of Yale University; Trevor Arnett, a vice-president of the
University of Chicago; and Wickliffe Rose, the star director of
the Rockefeller Foundation's International Health Commission.
The committee met at least twice and presented its report at the
end of May 1925.^^^

The two-page report, written by Vincent and Rose, tersely
dispensed with Gates' old policy. It noted that the GEB, the
Rockefeller Foundation's numerous divisions, the Laura Spel-
man Rockefeller Memorial Fund, and the International Educa-
tion Board all had dealt with and financially aided taxpayer-
supported universities and other institutions. The report politely
acknowledged that in 1906 Gates' policy was "sound," but in
1925 it was clearly "unwise to adopt principles so rigid as to
prevent occasional contributions to medical schools whose
growth might be of importance in a national system of medical
education." With Gates boycotting the meeting and Wallace
Buttrick conveniently absenting himself so as not to have to vote
against his friend, the board made the de jure policy coincide with
the Rockefeller foundations' practice.'"

The reversals of the full-time contracts and the policy on state
universities were too much for Gates to accept. Still fuming in
October, he resigned from the GEB executive committee.'^"*

The same revision was underway at the Carnegie Foundation,
which was unable to join the GEB and the Rockefeller Founda-
tion in aiding the University of Iowa because of opposition from
old-timers among its trustees, men like Elihu Root, a corporate
lawyer and former Secretary of State.'" The foundations and

Reforming Medical Education I 185

individual capitalists had lost their fear of State-run institutions.
Indeed, many financiers and industrialists, adherents of the new
corporate liberalism, saw great possibilities for stabilizing their
markets and profits in cooperation with the State. Sufficient
initiative in developing legislation and executive department
agencies bore fruit in the creation of regulatory agencies that
enabled the most powerful sectors of several industries to control
and regulate their industry themselves. Capitalists, corporate
managers, and professionals in America were coming to see the
State in a new light. Corporate liberalism embraced the State as
the guarantor of a stable, profitable economy. ^^^

The state universities were no exception. In the years ahead,
all the major foundations gladly developed programs at state
universities as freely as they used private universities. As with
physicians and medical education, the more expensive it became
to operate universities, the more the universities — state and
private alike — turned to any agency or organization offering
money. If money was offered for developing computer sciences,
there were long lines of university presidents at the foundation
doors explaining how strong their mathematics, statistics, and
electrical engineering departments were and how well they
worked together in the campus' fledgling program in computer
science. Just as with medical schools, a major foundation would
fund a few key schools to develop model departments or pro-
grams. And soon thereafter other universities would be copying
them or refining some problem area in a similar program, hoping
to get on the bandwagon of money for research and to attract
new faculty. The strategies developed in medical education
were refined and applied by numerous foundations in a broad
array of programs down through the years.

This willingness to use state universities and other state organ-
izations came partly from the changed attitude of the bus-
iness class toward the State, accepting the necessity and value
of State intervention in the economy. But foundation officers and
trustees had other reasons as well. State universities performed a
valuable role by conducting foundation-designed programs at
taxpayer expense. Just as the General Education Board had
fostered the development of vocationally oriented secondary
schools in the South, for which taxpayers picked up the major

186 I Reforming Medical Education

tab, its provisions for development grants in medical education
and other fields committed a university to continue to support the
new program once foundation funding was cut off. Gates had
always supported this tactic for objectives outside the university,
but to Gates the university was too essential an institution to be
entrusted to "the people."

The decisive argument for including state universities in
foundation programs, however, was necessity. In 1908 Andrew
Carnegie dropped his opposition to including state university
faculty in his foundation's retirement plan because in the Midwest
and the West, state universities were the dominant institutions of
higher education. The same understanding convinced John D.
Rockefeller, Jr., and other members of the GEB to support
state-run medical schools. If the foundations were to develop a
system of higher education, it was necessary to include the pre-
dominant type of institution.

Finally, professionals as a group had demonstrated their value
and loyalty to the objectives of the foundations. The foundations'
own professional staffs had earned the trust and confidence of
their employers — the financiers, industrialists, corporate lawyers,
and university presidents who sat on the foundations' boards of
trustees. Most staff officers felt trust in their fellow professionals
in the field. Gates himself trusted professionals whom he hired
and those who worked with his programs although at the end of
his career he disagreed sharply with them. Rockefeller, Jr., voted
with the board against Gates to rescind full-time binding con-
tracts and to fund state university medical schools; he did so
because he believed them important to the very goals of class
domination that he shared with Gates. The foundations were not
captured by their officers, as Gates asserted. Rather it was the
professionals who were captured by the foundations. They did for
the foundations what other members of the professional-
managerial stratum had already been doing for the same people's
industries and financial organizations.

Whether an economist or medical doctor teaching and doing
research in a university or developing and implementing pro-
grams in foundations, professionals saw foundations supporting
the development of their fields, providing for their livelihoods,
promoting expanded opportunities, and rewarding excellence.

Reforming Medical Education I 187

What could be wrong in cooperating with such foundations?
Weren't they, after all, run by such esteemed men as university
presidents, corporation directors, and other professionals?

These were the very relationships and attitudes encouraged by
Gates and other self-conscious strategists who built the founda-
tions and gave them purpose and direction. Like the medical
schools in Gates' and Flexner's funding strategy, the leading
foundations won the flattery of imitation by their weaker brothers
and sisters. Gates was indeed the pillar of the General Education
Board and the Rockefeller Foundation until his semi-retirement
in 1917. Although his successors modified some of his policies
and tactics. Gates' goals and strategies seemed inscribed in stone.

Corporate philanthropies continued to find their mission in
making capitalist society work better. Sometimes they tried to
make it work more justly, but even then it was because gross
injustice leads to movements for radical change. Generally, they
have followed the corporate liberal view developed in the
Progressive era and later joined by Rockefeller, Jr. His son
David, head of the Chase Manhattan Bank, recently summed
up this perspective, still popular in business and dominant in
foundations:

In view of the emerging demands for revision of the social contract,
a passive response on the part of the business community could be
dangerous. ... So it is up to businessmen to make common cause
with other reformers — whether in government or on the campus or
wherever — to prevent the unwise adoption of extreme and emotion-
al remedies, but on the contrary to initiate necessary reforms that
will make it possible for business to continue to function in a new
cHmate. . . . '^"^

If the foundations lost their fear of the State, it was not
because they had turned aside the objectives or general strategies
of people like Gates. They pursued the same goal of rationalizing
higher education in general and medical education in particular to
make them better serve capitalist society, and hke the dominant
view within the Rockefeller boards (but unlike Gates' personal
view), they adopted corporate liberalism's perspective that the
State is a necessary aid in rationalizing industries, markets, and
social and educational institutions alike.

188 I Reforming Medical Education

SUMMING UP

The reform of medical education led to a contest over who
would control medicine and for what ends. At the end of the
nineteenth century laboratory scientists and elite practitioners
formed an alliance to promote scientific medicine, revamp the
AM A, win hcensing legislation, and begin reforming medical
education. Abraham Flexner's report for the Carnegie Founda-
tion capped the drive to eliminate proprietary medical schools,
the pariahs of all proponents of scientific medicine. Proprietary
schools, sensitive to the needs of the average general practitioner,
had served the needs of most students going into family practice
while their faculty enhanced their incomes with student fees and
consultations referred by former students. These commercial
schools, however, churned out "too many" doctors, resisted
control by medical societies, and were completely inadequate to
providing the scientific, research-oriented medical education that
was desired by the profession's reform leaders and by capitalist
philanthropies.

Focusing on "commercial" medical schools and their low
standards, the Flexner report articulated criticisms of American
medical education and a program for reform that unified elite
practitioners, medical scientists, and philanthropists. With the
rapid decline of proprietary schools in the 1910s, however, the
basis of unity evaporated, and more fundamental conflicts
emerged.

The organized medical profession, in particular the AM A,
which represented practitioners, wanted to control entry into the
profession, assure that the training of physicians upheld the newly
established confidence of the public in doctors' technical ability,
and ensure that medical schools provided material support and
propaganda to continue the dominance of scientific, technologi-
cal medicine.

The new academic medical men, especially laboratory scien-
tists, saw the medical centers as their turf. They wanted a greater
share of the money spent on medical care, and they wanted,
through their medical centers, to control all health care services
and facilities. It made sense, they argued, for those who were the
source of medical science to direct the resources of the new
scientific medical system.

Reforming Medical Education I 189

Foundations, claiming objectivity from their position above
interest group squabbles, wanted to rationalize medical care, to
create an efficient and unified system that would contribute to the
health of the people. To that end, the General Education Board
and the Rockefeller Foundation together gave more than $100
million to transform medical education. Like the committed
academicians, they believed medical schools were the pivot of an
increasingly technological system of medicine.

The Carnegie Foundation stepped onto center stage before
the conflicts between medical scientists and elite practitioners
reemerged. Their support for the Council on Medical Education
encouraged reform-minded practitioners and science-oriented
academics vying for control Flexner's report supported practi-
tioners' insistence on closing down medical colleges and raising
the social class base of the profession, and academicians got
support for channeling endowment and construction money into
medical schools. The capitalist class was encouraged that a medi-
cal care system useful to and compatible with its interests was at
last at hand. The Carnegie Foundation, under Henry Pritchett's
personal guidance, lent its prestige and legitimacy to the profes-
sion's own strategy.

The General Education Board and the Rockefeller Founda-
tion, under Frederick T. Gates' direction, jumped in with a
different strategy. Rather than supporting the scheme of the
profession's leadership, which sought unity among academics and
practitioners, the Rockefeller philanthropies supported the domi-
nance of the medical scientists. Practitioners espoused capitalist
values in wanting to make a profit from their professional services
qua small business. But Gates and other foundation leaders had
in mind a more important political and economic role for
medicine, a role that required that health care be organized along
the most efficient and productive lines possible under leadership
that had demonstrated its support for the interests of the greater
capitalist society. Just as the AMA Journal had warned at the
turn of the century, there were dangers in letting wealthy
capitalists formulate their own philanthropic designs. ^^* The
GEB's full-time plan attacked the interests of cUnicians and the
organized profession's ties to the medical faculty.

The differences in the Carnegie and Rockefeller strategies can
be traced to Pritchett and Gates. Pritchett, before organizing the

190 I Reforming Medical Education

foundation for Andrew Carnegie, had been president of MIT and
before that an astronomer for the U.S. Coast and Geodesic
Survey. He was a scientist and a professional, and he was
concerned about developing and maintaining a sufficient supply
of engineers and trained personnel for industrial and government
needs. Gates was a former minister and, since the 1890s, a
director of industry and finance. Gates' ministerial background
probably contributed to his perception of the role of social
institutions as an important superstructure for society. His daily
experience with business affairs from his perch at the top of the
capitalist class gave him a broad perspective on the needs of
capital.

Though these two men were significant in shaping their
foundations' policies, the differences between them were not
personality differences. They differed on political questions —
what will best serve the needs of capitalist society? — and their
personal histories are merely sources for understanding how their
differing political perspectives developed. Both men and both
foundations supported rationalizing medical care. Gates foresaw
the problems with the medical profession that Pritchett only later
appreciated. Pritchett supported the profession's own plan of
action for several years before he became piqued at the narrow
concerns of the AMA and Bevan in particular.

Bevan and other clinicians leading the AMA resented the
General Education Board's attack on clinicians' interests. The
Rockefeller philanthropies had become "a disturbing influence
by dictating the scheme of organization of our medical schools,"
Bevan wrote to Pritchett. "Their position has become a real
menace to sound development." The GEB had been "badly
advised by men who are laboratory workers and teachers of
anatomy and pathology," he complained. These men regarded
"the laboratory as representing the science of medicine, and they
rather feel that clinical medicine is not scientific." Bevan argued
that in the training of physicians "the controlling influence must
lie with the teachers of clinical medicine. "^^^ But Pritchett had
seen the results of leaving medical education to the practitioners'
singular concern for their own interests and their disregard of the
larger goal of rationalizing education in the society.

By 1920 the elite practitioners broke off their alUance with the
medical academicians and other supporters of rationalized medi-

Reforming Medical Education I 191

cal care. A plan for compulsory sickness insurance sponsored by
the American Association for Labor Legislation — a corporate
liberal organization of social reformers, enlightened capitalists,
and a few labor leaders — had won the support of a few key men in
the AMA beginning in 1915. From the perspective of the time,
the efforts to rationalize medicine seemed to physicians and
foundation people alike to be leading to the demise of the private
practitioner. In 1915 Welch rather condescendingly urged that
"every effort ought to be made to rescue this situation," to
preserve the "fine" institution of the family doctor. '^^ The dour
prognosis for private practice medicine was definitely premature.

As local medical society leaders caught on to "the profession-
al philanthropists" and their attempts to "put something over on
us to our detriment," the Progressives within the AMA were
denounced. The academics, like Welch who had been elected
AMA president in 1909, were by then isolated. By 1920 at least
60 percent of the country's doctors were members of the AMA. '^^
With so many physicians joining up to support practitioners'
interests, with the academics out of leadership and the Progres-
sives, like Alexander Lambert, in retreat, the conservative
leadership of the practitioners prevailed, a reign uninterrupted to
this day.^"

By the time Gates resigned from the General Education
Board's executive committee in 1925, the efforts to rationalize
medical care had not gotten as far as Gates had hoped. The
constraints on his program notwithstanding, Gates' position
became the established foundation direction in medicine for half
a century.

CHAPTER

Epilogue: A Half-Century of
Medicine in Corporate
Capitalist Society

A VIRTUAL revolution transformed American medicine from 1890
to 1925. The medical profession ascended from ignominy and
frustrated ambition to prestige, power, and considerable wealth.
Medical science was developed from a mere gleam in the pro-
fession's eye to an established and powerful force in society.

This American success story is attributable to several histori-
cal developments. First, industrial capitalism created a new role
for science and its application. Science was elevated from a
gentlemen's avocation to a vital element in the competition for
increased productivity and decreased labor costs. Scientists seized
the opportunity to be of service to the masters of this new
economy, and they were in turn rewarded with money and
facilities for their work and prestige for their achievements and
themselves.

As the organization of production grew larger and as the
financial and legal underpinnings of capital grew more complex,
capitalists recognized the need for managers and professionals to
run their factories, their banks, and the social institutions that
serviced the society and held it together. Universities became the
main vehicles for training this new stratum of managers, profes-
sionals, and scientists and for organizing scientific research.

Second, physicians who were dissatisfied with the state of
their profession recognized the economic and political, as well as

Epilogue I 193

technical, advantages of applying science to their rather crude
art. By embracing scientific medicine, leading practitioners
bolstered their crusade for a monopoly over the practice of
medicine. The forefathers of academic medicine chose "glory"
over "gold" and advanced the cause of medical science. Working
together, elite doctors and medical researchers adopted the
analytic methods and rubrics of science and lodged the training of
physicians in the university. They sought designation as the
society's legitimate professionals in matters of health and illness.
With this strategy, they won the political and financial support of
the new corporate class.

Third, mobilizing the power of corporate wealth in the social
sphere, foundations brought unprecedented aid to the promotion
of scientific medicine and to the reform of medical education. As
the guiding force for the reform and development of institutions
to serve the scientific, educational, and cultural needs of capitalist
society, foundations played the leading role in financing neces-
sary changes in medicine. By providing the carrot of subsidy to
capital-hungry medical schools, foundations secured a position of
enormous power in medicine from 1910 to the 1930s. In this
period, foundations gave some $300 million for medical educa-
tion and research. Rosemary Stevens concluded, "Foundations
were thus the most vital outside force in effecting changes in
medical education after 1910."^

FREDERICK T. GATES AND

THE ROCKEFELLER PHILANTHROPIES

Of all the foundations, the General Education Board was, in
the boastful but true words of Abraham Flexner, "the leading
influence in remodeling American medical schools on the Hop-
kins plan."^ The more than $82 million they applied to medical
education reform by 1930 had an enormous impact because they
employed a carefully conceived and faithfully followed strategy in
which they consciously analyzed the interests and goals they
wished to further, mapped out a plan for achieving them, and
imposed necessary financial and programmatic conditions on
recipient schools. The GEB sought a rationalized medical care
system, directed by medical schools that were committed to a
scientific and technological type of medicine.

194 I Epilogue

Frederick T. Gates and the General Education Board did not
achieve everything they sought, but even by 1929, the year Gates
died, they had firmly established three important strategies in the
development of medicine in the United States. First, Gates and
the GEB created an important role for foundations — to give
direction to the development of American health care. They
assumed the right to define what kind of health care their society
needed, and they used their tremendous corporate wealth to real-
ize that vision. In its early years, the GEB provided a leadership
that was widely followed by other foundations and by wealthy
individuals. Gates and his associates achieved power over Ameri-
can medicine partly because of the wealth they wielded but, more
fundamentally, because they articulated the interests of the corporate
class in a strategy that won sufficient support to succeed.

Second, as part of their strategy. Gates and the Rockefeller
philanthropies promoted the dominance of scientific, technologi-
cal medicine. Because of the ideological appeal of this new
medicine and its presumed technical effectiveness, the philan-
thropies and many other groups in industrialized capitalist
societies embraced the analytic theories and the research and
development methodologies of medical science and advocated
the organization of medical practice solely around technological
medicine. By 1930 they had firmly established the importance of
well-equipped medical centers for all medical practice and health
care organizations as well as for training new medical profession-
als and for developing knowledge and technique.

Finally, Gates and his followers in and out of the GEB began
the long struggle to rationalize medical care, that is, to coordinate
and integrate the different elements of the system so that it
performs its designated functions. One of the main obstacles in
that struggle has been private practice physicians, whose desire to
profit from other people's sickness and suffering evoked angry
opposition and accusations of "commercialism" from Gates and
his colleagues. Because the interests of the organized medical
profession conflicted with the goals of disseminating the technical
benefits and ideological influences of medicine as widely as
possible, the Rockefeller philanthropies attacked the profession
head-on. Although they did not succeed in vanquishing the
medical profession, they did initiate the strategy that was
continued and refined by foundations for decades to come.

Epilogue I 195

The forces set in motion during Gates' time continued to
develop over tlie next half-century, as the remainder of this
chapter will make clear. Although foundations continued to
provide leadership in medical affairs, the State soon took over
from the foundations the dominant financial role in the reform
and development of medical care. The State continued foun-
dation-developed strategies of rationalizing medical care and
developing technological medicine. This chapter will focus on two
important developments that created conditions Gates and his
contemporaries did not anticipate.

First, technological medicine created opportunities for the
development of new medical industries that came to play
powerful roles in medical politics as well as in the medical
economy. Rationalization was simply applied to this private
market sector, faciHtating the expansion and control of capital-
intensive medical industries but failing to correct the deficiencies
inherent in market-distributed medicine.

Second, the State's continued emphasis on medical technolo-
gy served the corporate class interest in its own legitimation and
the interests of medical technology interest groups. But the
explosively inflationary effects of medical technology in a market
system eventually undermined support for its expansion and
encouraged the partial substitution of other legitimizing ideolo-
gies. As we will also see, neither of these developments has
produced a medical care system that meets the widely recognized
needs of the population.

RATIONALIZING THE MEDICAL MARKET

THE COMMITTEE ON

THE COSTS OF MEDICAL CARE

One of the milestones in foundation-led efforts to rationalize
health care was the Committee on the Costs of Medical Care
(CCMC). The committee was formed in 1927 and was provided
with a million-dollar research and expense fund by eight founda-
tions, including the Rockefeller, Rosenwald, Macy, Milbank, and
Carnegie philanthropies. Over the next four years the CCMC's
staff and consultants turned out twenty-six reports, and in 1932,
the committee concluded with a final report that at the time
seemed sweeping.^

196 I Epilogue

The report documented the great disparity in medical care
according to income. Middle- and upper-income families aver-
aged substantially more physician visits per person each year than
lower-income families. Hospitalization, dental care, preventive
care, and eye care were likewise strongly related to family
income. The committee's critical analysis implied an important
principle: The sale of medical care as a commodity distributes
that care to those who can pay for it rather than on the basis of
need. That is, it is distributed according to the society's class
structure.

The committee recommended reorganizing medical care into
group practices and developing more hospitals rationally distrib-
uted where needed, voluntary insurance plans to spread the
uneven financial risks of illness among the population, and
coordination of health care by the government. The thrust of
these recommendations was to reduce the runaway power of the
medical profession over health care by weakening the fee-for-
service system of private practitioners, strengthening the position
of hospitals in the organization of health services, and organizing
the callous market for medical services into a rationalized,
regulated system."^

The report articulated and legitimized the perspective and
goals of the medical care reform campaign, much as the Flexner
report had done for the medical profession's campaign for
medical education reform some twenty years before. The recom-
mendations were supported by virtually all of the committee's
thirty-eight public health officials, business leaders, foundation
officers, medical school faculty members, social scientists, labor
union officers, and government officials. Through the CCMC,
they formed a loose coalition whose leaders included some
foundation officers and staff members who had worked for or
with Gates and the Rockefeller philanthropies. Over the years
this coalition, soon joined by hospital administrators and some
health insurance industry officers, led efforts to rationalize
medical care.

Nine representatives of organized medicine on the committee
dissented from the majority report, attacking the group practice
and prepaid insurance proposals and supporting voluntary insur-
ance only if it protected fee-for-service practice under local
medical society control. Although the committee majority advo-

Epilogue I 197

cated a continuation of privately controlled medical care, their
proposals for more publicly organized financing and increased
coordination of care were taken as a declaration of war by private
practitioners. The AM A Journal rose to the occasion with a
classic in hyperbole:

The alinement is clear — on the one side the forces representing the
great foundations, public health officialdom, social theory — even
socialism and communism — inciting to revolution; on the other side,
the organized medical profession of this country urging an orderly
evolution guided by controlled experimentation which will observe
the principles that have been found through the centuries to be
necessary to the sound practice of medicine.'

Efforts of this "revolutionary" coahtion in the 1930s to
develop some form of national health insurance met defeat at
the hands of the AMA's well-funded lobbying machine. "The
controversy between 'organized medicine' and many major
interests in our society became intensified," I. S. Falk, research
director for the CCMC, recently observed, "and a dichotomy of
national proportions began to take shape. "^ The AMA, as an
interest group, declared civil war against the corporate class-
supported efforts to rationalize medical care. A long succession of
national health insurance bills was submitted to Congress by the
reform coahtion, but they were defeated by the AMA wielding
the medical profession's wealth and the resulting power to
influence public opinion and legislators' votes.

DOCTORS AND THE CAPITAL-INTENSIVE
COMMODITY SECTOR

In the long run, however, the medical profession's autonomy
was undermined by the same economic forces that contributed to
their seemingly irrepressible rise in power, wealth, and status.
Just as outside capital was needed to finance the development of
medical science and the reform of medical education, technologi-
cal medical care requires a financial base that cannot depend on
the fees paid by individual patients. The dependence of physi-
cians on technological medicine and the requirements of techno-
logical medicine for large capital and operating expenditures
eventually weakened the poHtical autonomy of the profession.

Hospitals, for example, provided doctors with new diagnostic

198 I Epilogue

and treatment facilities that made physician care technically more
sophisticated and enhanced the prestige of doctors' roles. But
hospitals required increasing funds and a stable system of finance.
Since physicians could not themselves provide the capital to build
and equip hospitals, the hospitals had to depend on philanthropy,
government, and commercial banks for their needed capital. As
the demands for operational funds increased, hospitals had to
look beyond the billing of individual patients to the resources of
insurance companies and the government. Similarly, physicians
depended on medical schools to produce advances that might be
applied to medical practice, to train new members of the
profession in science-based medical theories and techniques, and
to socialize new members in norms that made the profession
cohesive and powerful. They also depended on drug companies
to produce their materia medica — the essential base of their
practice since prescription drugs gave doctors new power by
making the public see a physician in order to be allowed to obtain
the fruits of medical research. Prescription drugs, hospital care,
medical equipment and supplies, and health insurance all quickly
became essential commodities of the medical kingdom over
which physicians reigned.

Private practice medicine had been founded upon simple, or
petty, commodities that the physician himself could produce and
sell. But technological medicine made physicians dependent
on capital-intensive commodities, ones that require substantial
capital investments and a good deal of hired labor to produce.''
For decades, this development redounded to the advantage of the
profession. Medical technology enabled the profession and these
new interest groups to further divide medical care into discrete
service units and products that could be sold in the medical
market. This intensive "commodification" of medical care en-
larged the number of medical commodities that could be market-
ed. Physicians assumed a new role in this market as middlemen as
well as more "productive" producers. They were able to control
more and more of the increasingly lucrative medical market,
claiming a monopoly of expertise and authority over health care
and over the increasing numbers of health workers. But the
profession's growing dependence on capital-intensive medicine
contained the seeds of their poHtical decline — the loss of their
ability to protect the economic relations on which private practice

Epilogue I 199

was founded. This contradiction was focused especially in the
hospital.

Hospitals, as the Committee on the Costs of Medical Care
demonstrated, were inadequate in number and not rationally
distributed according to need. In the 1930s, the Julius Rosenwald
Fund gave the American Hospital Association (AHA) $100,000
and the loan of staff member Dr. C. Rufus Rorem (who had been
a senior researcher for the CCMC) to help the AHA rationalize
hospital administration and organize Blue Cross associations.*
The foundation and the AHA hoped the hospital insurance
program would provide a stable income for hospitals hard hit by
the depression, centralize and integrate local health services
around hospitals, and further the cause of voluntary health
insurance at least for hospital expenses.

Blue Cross plans were a phenomenal success and proved the
value of "third-party" payment mechanisms. The risk of medical
misfortune was spread among many individuals and families,
enabling them to have access to more expensive kinds of care.
The demands of labor unions for greater economic security and
more benefits encouraged the spread of work-related group
plans. By 1947, after several years of cost-plus government war
contracts. Blue Cross enrollment reached 27 million members, 19
percent of the population. After the war commercial insurance
companies, following the Blue Cross lead, pushed energetically
into the health insurance market they had previously all but
ignored. Blue Cross and commercial health insurance companies
developed this new commodity into a major industry — totaling
$39 billion in premium income in 1977-and strengthened hospi-
tals' finances and their position in the medical delivery system.'

The groups that had coalesced around the Committee on the
Costs of Medical Care pressed on with their campaign to reform
medical care. Since these interest groups favored coordinating
care under the leadership of medical schools with hospitals as the
"logical center" of the system, hospitals became ardent advocates
of reform and rationalization that expanded their roles and
power. With the support of the AM A, the loose coalition won
passage in 1946 of the Hospital Survey and Construction Act,
better known as the Hill-Burton Act.^° The Hill-Burton Act was
another milestone, not merely because of the $5 billion it has
since provided for hospital construction and modernization, but

200 I Epilogue

because it marked the entrance of the State as a principal power
in the medical care system.

THE STATE: RATIONALIZING
THE PRIVATE MARKET

After World War II, the State became the conduit for more
funds to expand and rationalize health care, taking over from
foundations the primary role of financing reforms in medical
education and later providing the operating funds for medical
schools and medical care itself. The State's intervention would
not, of course, be neutral. The State's interests are larger than
those of any interest group, whether in health or in the larger
economy, but the State is only relatively autonomous. In devel-
oped capitalist countries, it shares a mutual dependence on and
an interdependence with the dominant economic class. Top govern-
ment officials come disproportionately from the corporate class.
The government's tax revenues depend on the "health" of the
capitalist economy. And the government promotes and protects
the larger interests of the corporate class, particularly its domi-
nant sectors. Though it might be to the disadvantage of any one
company at a particular point in time, in the long run, govern-
ment regulation benefits the dominant firms in an industry by
permitting monopolistic concentrations of economic power but
preventing those concentrations from turning into devastating
wars of economic conquest. The State facilitates the process of
capital accumulation and legitimizes the existing capitalist soci-
ety. The explicit reliance of the corporate class on the State was
articulated by corporate liberals in the Progressive era. Although
the State's intervention in organizing production and social
relations was initiated during that period, it matured rapidly
during the Great Depression and became the ruling order during
and following World War II. The State became as important to
medicine as it is to the larger economy. ''

While the commitment of the State to rationalizing medical
care was clear, it was not clear whether it would rationalize it
under existing private ownership and control or whether it would
rationalize it under government ownership and control, as many
Western European nations were doing. The consequences would
be important.

Rationalizing health services under private ownership and

Epilogue I 201

control would accelerate the transformation from simple com-
modity production to capital-intensive commodity production
while nationalization would begin to transform health services
from commodities into a public service function. The direction
was not decided as a matter of policy. It was shaped and
constrained by economic and political developments in medical
care and the larger society— in part by the AMA's opposition to
national health insurance and the lack of a sufficiently strong and
threatening working-class movement, in part by the growth of the
powerful capitalist commodity sector in medical care, and in part
by the role of the State in advanced capitalist countries.

In Europe national health insurance programs were estab-
lished either by fairly conservative governments in response to
militant working-class revolt that threatened to overturn State
power and capitalism itself or by labor or social democratic
parties that won sufficient electoral victories. In 1883 Bismarck
established the Sickness Insurance Act to help stem the growing
support for socialism among the German working class. In
England Lloyd George and the Liberal party enacted the
National Health Insurance Act in 1911 to win the workingmen's
swing vote away from the socialistic Labor party. When the
Labor party finally came to power after the Second World War, it
nationalized the hospitals and the insurance system in the
National Health Service Act.

In the United States the closest the working class came to
threatening ruling powers was during the Progressive era when
the Socialist party won significant election victories and its
militant wing was gaining support for more revolutionary activity.
In 1916 the American Association for Labor Legislation
(A ALL), an alliance of Progressive businessmen and reformers
and nonsocialist labor leaders, introduced its model compulsory
medical insurance bill into several state legislatures. Although
some Progressive AM A officials supported the bill, the proposal
was crushed by private practitioners who organized within and
outside the AMA to defeat this "attack"^' and by the conserva-
tism and political repression that swept the country following
America's entry into the war.

In the absence of a sufficiently independent and mihtant
working-class movement, national health insurance continued to
be defeated in the decades that followed. Throughout the 1930s

202 I Epilogue

and 1940s the AMA carried on its vehement opposition to any
federal intervention into the financing of medical care. Liberal
reformers tried to get national health insurance included in the
Social Security Act as part of the New Deal response to the Great
Depression and the militant organizing among the unemployed
and industrial workers. But the AMA was powerful enough to
strike any mention of health care from the Social Security bill. In
the 1940s the AMA waged well-funded, energetic, and success-
ful campaigns against the Wagner-Murray-Dingell and Truman
proposals for a nationalized health insurance system. The associa-
tion even came around to supporting voluntary private health
insurance as "the American way" to undercut the growing
support for a government-run national health insurance pro-
gram.'^ Finally accepting defeat, liberal proponents of medical
care reform retreated to advocating proposals for government
health insurance restricted to the beneficiaries of Social Security
programs.

The depression and the Second World War firmly established
the principle of federal economic intervention to organize and
stimulate production and necessary social institutions and ser-
vices. The Hill-Burton Act was an example of that principle
extended to medical care. But the AMA continued its decades-
old opposition to increasing the number of medical students and
defeated proposals for direct aid to medical schools. Neverthe-
less, a back door was opened with medical research funds — which
the AMA welcomed as furthering the development of medical
technology — to help pay some of the overhead and salaries at
medical schools. In the 1950s construction grants and traineeships
for medical schools were finally approved by Congress because of
the intensifying public concern about a growing doctor shortage.
The AMA was learning the limits of its political power.''*

In the mid-1960s the advocates of rationalization won a major
legislative and programmatic victory over the AMA with the
passage of the Medicare and Medicaid bills, fallback programs
from earlier efforts to obtain comprehensive national health
insurance. Medicare is a Social Security program that covers most
hospital, physician, and related medical services for more than 95
percent of all Americans over sixty-five years of age. Medicaid, a
welfare-linked federal and state program, helps pay the health
care costs of people on welfare and other "medically indigent"

Epilogue I 203

persons. Bitterly and expensively fought by the medical societies,
the passage of Medicare and Medicaid signaled the further
decline of the medical profession's power and the growing
dominance of forces committed to rationalizing medical care.

Like private health insurance, these State subsidies and
"third-party" programs were parts of larger strategies to rational-
ize health services. Since attempts to nationalize even health
insurance appeared blocked, proponents of rationalization
seemed content with rationalizing the private medical market.

THE GROWTH OF
CAPITAL-INTENSIVE COMMODITIES

While private health insurance provided a stable cash flow on
which hospitals could depend and expand, Medicare and Medi-
caid seemed a Umitless largess. They fed the market competition
between hospitals and the avariciousness of hospital administra-
tors, construction companies, banks, the medical supply industry
and others who could get their hands into the public till.
Following the introduction of Medicare and Medicaid, hospital
and physician fees rose each year at twice their previous rates of
increase, and the cost of medical care in general rose twice as fast
as inflation in the rest of the economy. Capital investment per
hospital bed rose three times as fast in the five years after
Medicare and Medicaid began as it did in the five years before,
reaching $56,000 per bed in 1976. Medicare and Medicaid picked
up an even bigger share of the medical care bill — $37 billion in
1977, a fourth of all personal health care expenditures from all
sources. ^^

Medicare and Medicaid, together with private health insur-
ance, effectively subsidized the rapid expansion of capital-
intensive medical care. Hospitals felt assured that everything
from automated blood-chemistry analysis machines (costing up-
wards of $100,000) to computerized axial tomography (CAT)
scanners (costing $300,000 to $750,000) could be paid for.
Expansion has resulted in as many as 100,000 excess hospital beds
in the country, averaging about $20,000 per bed in annual
operating costs. ^^ Banks were among those who profited from this
expansion by providing hospitals with profitable commercial
loans, usually guaranteed by the government.^"' CHnical laborato-

204 I Epilogue

ries, hospital and medical supply, drug, and nursing home in-
dustries similarly boomed.

An increasing share of the medical commodities being pro-
duced were capital-intensive ones compared with physician serv-
ices. The "average" person spent seven to eight times more on
physician and dentist services in 1977 than in 1950, but he or she
spent twelve times more on hospital care and forty-nine times
more on nursing home care.^* With the expansion of private
health insurance and especially with the passage of Medicare and
Medicaid, the power of physicians shrank relative to the increas-
ing economic and political power of the capital-intensive medical
sector. This sector has now surpassed the medical profession as
the dominant political force in medical care, mainly because of
the shared interests of three important groups.

THE "CORPORATE RATIONALIZERS"

Medicaid and Medicare are the offspring of the groups that
articulated the majority position of the Committee on the Costs
of Medical Care, helped the American Hospital Association
develop and coordinate the role of the hospital as the "logical
center" of the health care system, and secured passage of the
Hill-Burton and other federal aid programs. They are what
Robert Alford calls the "corporate rationalizers,"^^ favoring the
coordination and organizational integration of the different parts
of the medical care system, or as they refer to it, the "non-
system."

In reality, there are three distinct groups that favor rationali-
zation— two interest groups and a class. One interest group is
composed of bureaucratic professionals — academic physicians
and public health officialdom, advisers, planners, and consul-
tants. They are the functionaries of bureaucratically organized
medical care who staff the increasing layers of government units,
medical schools, and health agencies and organizations of all
types. Although the bureaucratic professionals generally main-
tain that the major goals of medical reform are equal access for
the poor and racial minorities and more accessible primary care
for everyone, they have a material interest in such reforms
because they gain power and status with each new level of
rationalization. They are the technicians and managers on whom

Epilogue I 205

foundations and government rely for planning and conducting the
reforms that are proposed and implemented. Bureaucratic pro-
fessionals are the least powerful of the three groups because their
positions are dependent on those whom they serve.

The second interest group among the rationalizers are those
industries with a direct economic stake in the medical market —
the market rationalizers. The two most active industries in
this group are hospitals and health insurance carriers. In 1976,
voluntary hospitals, as privately owned nonprofit hospitals are
called, claimed 70 percent of the beds, 72 percent of the average
daily patient census, and 76 percent of the assets of nonfederal
short-term hospitals. ^° And they took the lion's share of the more
than $65 bilHon spent on hospital care in 1977, making them a
major economic force in the health sector. While their existence
does not depend on the medical commodity marketplace — that is,
they would exist even in a nationalized health system — their
autonomous power is greatly enhanced by this privately con-
trolled market system. Like any corporation, hospitals have
entrepreneurial power to capture what they can of the market, ^^
accumulate a surplus of revenues above expenses, and allocate
resources within the constraints of the market.

Similarly, Blue Cross and Blue Shield, though "not for
profit," aggressively marketed about $19 billion of their insurance
products in the medical market in 1977. Like the "Blues,"
profit-making insurance companies, which collected about $20
biUion in health insurance premiums in that year, depend for
their existence on the market system for medical care. The
traditionally close ties of Blue Cross and Blue Shield to hospitals
and medical societies, respectively, have weakened in recent
years because of public pressure over rapid rate increases which
brought stronger regulation and formal separation from their
parent bodies. The Blues and commercial carriers now share
increasingly similar interests in holding down medical costs to
what the premium market will bear. Together with drug compa-
nies, banks, and other profit-making concerns, hospitals and
insurance companies have a direct stake in the ascendance of an
expanding commodity system in medical care, especially with the
enormous State subsidies represented by Medicare and Medicaid
or a national health insurance program. Their interest in rational-
ization is limited to expanding the market for their wares and

206 I Epilogue

protecting their respective places in the increasingly rationahzed
system they see as inevitable.

The third group of rationalizers is the corporate class, in-
cluding those who own or manage the nation's corporate wealth
and foundation trustees and officers who supervise the expendi-
ture of that portion of the wealth that is devoted to managing
social institutions. The contemporary corporate class includes the
main shareholders and the top officers in the largest corporations.
It certainly includes the one-half of one (0.5) percent of the
nation's population who own one-fifth of all the nation's wealth,
including half the net worth of all bonds and corporate stock."
Economic power is similarly concentrated among corporations, a
minute fraction of which (0.06 percent, or 958 corporations) held
a majority (53.2 percent) of all corporate assets in 1967. Similar
concentrations are found in the separate economic sectors —
manufacturing, banking, and insurance among them."

Power is concentrated among foundations, too. Of the 2,818
foundations in the United States in 1976, the top eight (represent-
ing three-tenths of one percent of all foundations) held an
average of $948 million in assets while three-fourths held less than
$5 million each, and another fifth had assets of $5 million to $25
million. ^"^ The top eight — including such important ones in the
health field as the Robert Wood Johnson, Rockefeller, Kresge,
and Kellogg foundations — have an enormously disproportionate
impact on educational, scientific, and cultural institutions. Al-
though the members of this class do not think alike by any means,
they share a common interest in maintaining the capitalist
economic system and their collective positions of power and
wealth in it."

As my analysis of the involvement of earlier capitalists in
medicine demonstrates, the corporate class has a compeUing,
but narrow interest, in the health of the people and the kind
of medical care provided for them. But that interest extends only
to assuring that the population maintains sufficient physical and
mental health to provide an adequate work force and that
medical care encourages dependence on technical and profession-
al management of individual problems. Capitalists may be con-
cerned about accessibility, as Gates was, because an inaccessi-
ble system cannot perform its designated functions. They may
even favor the complete nationalization of medical care, as

Epilogue I 207

Vicente Navarro points out,^^ to raise productivity or placate
threatening movements and bolster the failing legitimacy of the
system.

However, corporate owners and managers and foundation
trustees and officers are ideologically reluctant to view private
ownership and control as inherently problematic in providing for
social needs. Members of the class who are associated with
corporations obviously profit directly from the private control of
capital accumulation while the influence of foundation members
derives from their foundations' investments in corporate wealth.
They thus share a material interest in ignoring any conflict
between private control of resources and the stated goals of
rationalizing medical care.

Bureaucratic professionals, medical industries, and the corpo-
rate class coalesced around their common interests — expanding
capital-intensive medical care and bureaucratic organization as
the main features of rationalization, being careful not to trample
on private ownership and control. Faced with this corporate
model of rationalization, how did the State respond?

THE STATE AND CAPITALIST MEDICINE

The State intervened with subsidy, incentive, and regulatory
programs to readjust the market system, decrease the market
economy's inequitable distribution of medical commodities, and
restrain the unusually inflationary forces of the medical market-
place. Although it has provided "categorical" programs for those
who could not afford essential medical services, the State has not
tried to replace the commodity market with an equitably distrib-
uted pubHc service. Because the power of the medical profession,
in the absence of sufficient countervaiHng pressure, blocked
efforts to nationalize the financing and delivery of medical care in
this country, the privately owned and privately controlled system
was simply expanded through direct subsidies and incentives.
Expansion and subsidy favored the development of a capital-
intensive commodity medical sector both because it was the
economically dominant portion of the medical market and be-
cause it was consistent with the ideological perspectives and
material interests of the corporate class.

Those corporation and foundation members who have no

208 I Epilogue

investment in profit-making medical industries see the health care
system as a support industry for the primary and secondary
sectors of the economy. But by the 1950s the powerful finance
sector of the economy, represented by insurance companies and
banks, had developed a large stake in the subsidized medical
market. Few members of the corporate class, even those without
profit-making medical investments, railed against "commercial-
ism" in medicine, as Rockefeller philanthropy officers had done
in their drive against private practitioners early in the century.
Even most bureaucratic professionals, who do not themselves
have a financial stake in profit-making medical care, preferred to
ignore the issue. ^"^

The more the State intervened financially in the medical care
system, the more likely it became that it would have to intervene
politically to control the system in which it had developed a
principal financial interest. Employers worried about the growing
cost of health plan benefits they were paying. In 1976 General
Motors spent more on Blue Cross and Blue Shield plans, about
one billion dollars, than it did on purchases from U.S. Steel. Steel
companies, banks, airhnes, and most industries were unhappy
about the 10 to 25 percent a year increase in the cost of employee
health insurance benefits. ^^ And unions were concerned because
every increase in health insurance rates (paid for through fringe
benefits) cuts into potential pay raises for their members. Other
health services "consumer" groups also criticized the shrinking
proportion of physicians and services devoted to primary care and
the rising expenses that consumers had to pay out of their own
pockets, in spite of increasing insurance coverage. Congress, the
executive branch, and state governments were fearful of their
impending fiscal crises in which expenditures were rapidly out-
stripping tax revenues; they wanted to restrain the rising costs
of their medical care programs, which had increased from a
fourth of total health expenditures before Medicare and Medicaid
began to more than 42 percent in less than ten years. ^^

By the time market conditions and rising State subsidies
necessitated rationalization, the only substantial profit-making
medical sector without sufficient protective support in the cor-
porate class or other powerful sectors of society was the petty
commodity sector — private practitioners. The control and regula-
tion of physician services seemed inevitable because doctors'

Epilogue I 209

orders for their patients' hospital stays and procedures were
important elements in the meteoric rise in tax dollars being spent
on Medicare and Medicaid as well as private expenditures for
health services. Prepaid group practices, which originated in the
1920s and were strongly recommended by the Committee on the
Costs of Medical Care, became a major part of the reorganization
plans of rationalizers. Despite long-standing opposition from
medical societies, the federal government promoted these pre-
paid plans, called Health Maintenance Organizations (HMOs).
HMOs have a built-in incentive to keep costs down because they
convert high utilization by patients from an asset to the provider,
as in fee-for-service practice, to a liability when a person gets all
his or her care for a monthly fee paid in advance. ^° Bureaucratic
organization seems destined to replace solo private practitioners.
In 1972, despite the AMA's enormous lobbying machine in
Washington, the rationalizing forces won congressional approval
of a bill to create Professional Standards Review Organizations
(PSROs) that would establish utilization review over individ-
ual practitioners' services to Medicare and Medicaid recipients.
Some state and local medical societies, wanting nothing to do
with outside review even if it were controlled by the profession,
threatened to boycott the required program. But the AMA
Journal, acknowledging the handwriting on the wall, soberly
warned physicians: "If we stand as a rock against the current, our
base will be eroded and we will be swept aside. Organized
medicine must remain elastic and adapt to our time. To do less is
to invite extinction in the manner of dinosaurs and dodos. . . .
There are perilous times ahead but we must participate if we are
to prevail. "^^ As an example of their new realism, the AMA
dropped its half-century-long opposition to any form of national
health insurance and put forth its own "Medi-Credit" proposal to
try to salvage for private practice physicians conditions that
would permit their survival.

DIVIDED THEY STAND

Just as the unity among elite private practitioners and medical
school faculty dissolved after their victory over traditional doctors
and medical sectarianism early in this century, so is the unity
among corporate rationalizers more fragile now that their victory
over private practice medicine is in sight. Hospitals, though the

210 I Epilogue

centerpiece of rationalized health care, have become the bete
noire to groups trying to contain rising health care expenditures.
The state and local Comprehensive Health Planning agencies,
mandated by Congress in the mid-1960s, failed to put a sufficient
brake on hospital expansion and escalating costs. Their suc-
cessors, a somewhat strengthened network of Health Systems
Agencies (HSAs) created by the National Health Planning and
Resources Development Act of 1974 (P.L. 93-641), are another
attempt to bring order to the economic chaos of the unregu-
lated medical market and to avert the fiscal bankruptcy of the
government's medical care programs. While these agencies, in
combination with state-run Certificate of Need programs, will
probably slow expansion of hospitals and their acquisition of very
expensive equipment, they are unlikely to bring the different
medical interest groups to heel.^^

Members of the corporate class, through business organiza-
tions and foundations, push for reform of medical care to im-
prove its delivery of primary care services and to rationalize its
organization and financing. The Committee for Economic Devel-
opment (CED), a policy organization with representatives from
nearly 200 major corporations, has urged the restructuring of
medical care into HMOs, the development of national health
insurance, and increased government planning and regulation
of medical care providers. ^^ Foundations similarly use their
corporate wealth to encourage the coordination of care around
hospitals and academic medical centers, with an emphasis on
promoting "front-line" or primary medical care so badly neglect-
ed by the technology-oriented, medical market. The Robert
Wood Johnson Foundation, with more than $1 billion in assets
derived from the Johnson and Johnson band-aid empire, spends
its funds entirely in the health field. The Rockefeller Foundation,
with assets over $700 million, the Kellogg Foundation, with
nearly $1 billion in assets, the Kresge Foundation, with more than
$600 million in assets, and others all place great emphasis on
reforming medical care.^'* Although their wealth is enormous, it is
dwarfed by the health expenditures of the federal government
each year. The foundations, therefore, concern themselves with
developing model programs, which may then be taken over by
the government, and with directly influencing policy in govern-
ment as well as in medical care institutions.

Epilogue I 211

The attempts of foundations and the State to rationalize
heahh care have simply been superimposed over the market
economy for health services. Despite their appealing rhetoric
favoring coordination, integration, and planning, bureaucratic
and corporate rationalizers are unable to control all the necessary
factors in the production and provision of health services and
products. ^^ Doctors, hospitals, insurance companies, the Blues,
drug and hospital supply and equipment companies, and medical
schools all seek the commanding role in the health system — or
at least the lion's share of its resources. Present rationalizing
strategies conceal the disparity between stated goals and political
and economic reality; they appeal to legislative and bureaucratic
mechanisms to unify and integrate the system.

The failure of one mechanism is taken as evidence of the need
for another patchwork mechanism. Endemic inflationary prob-
lems, caused in part by Medicare and Medicaid, were answered
with Comprehensive Health Planning agencies, and their failure
was the impetus for the creation of Health Systems Agencies
(HSAs). Falk, the research director for the Committee on the
Costs of Medical Care half a century ago, warned recently that
the powerful interest groups in medical care will all be reluctant
to let their interests be overriden by some higher social interest.
But he is left with the strikingly naive hope that these "resistances
will have to be overcome as far as possible by the reasonableness
of the proposals and the persuasiveness of the explanations, and
beyond that, by confrontations in the legislative arena. ''^^

Such mechanical solutions, which dominate health planning,
ignore the substantial political and economic power that simulta-
neously unites and divides the system's interests. The medical
care system has evolved into a glut of interest groups, none of
which has sufficient power to prevail by itself. Although the
proponents of corporate rationalization have prevailed over the
petty commodity sector, they do not share among themselves an
interest in the coordination and integration of the entire system.
However, their occasional bickering among themselves — for
example, over who will be regulated and how much^'' — should not
be mistaken for fundamental opposition. Corporate rationalizers
and organized medicine share an overriding and unifying interest
in the private ownership and private control of social resources.
Each group is best able to promote its own survival, growth, and

212 I Epilogue

profits if it is not subordinate to either the State or any other
interest group. Alford argues,

Differences between dominant and challenging interests should not
be overemphasized . . . because both professional monopoly and
corporate rationalization are modes of organizing health care within
the context of a market society. Both must avoid encroachments
upon their respective positions of power and privilege which depend
upon continuation of market institutions: the ownership and control
of individual labor, facihties, and organizations (even nonprofit
ones) by autonomous groups and individuals, with no meaningful
mechanisms of public control.^*

Thus the State has entered into the medical care arena very
much as the foundations had. Whatever the intent of the
supporters of specific legislative programs, federal and state
programs have, in sum, furthered the transformation of medical
care from simple commodities, produced and sold largely by
private-practice physicians, to capital-intensive commodities, pro-
duced and sold by bureaucratic organizations that assemble large
amounts of capital and hired labor and strive to accumulate a sur-
plus of revenue over expenses.

State intervention to rationalize medical care thus benefited
interest groups whose existence depends on technological
medicine — especially hospitals, health insurance carriers, and
medical technology industries — more than it helped the medical
profession, although doctors gained financially, too. How did
consumers fare in these developments? Did they also benefit
from the State's rationalization of the private medical market?

UP AGAINST THE MEDICAL MARKET

The combination of private and public third-party payment
programs has reduced the gross inequalities in utilization of
medical care, but these programs have neither eliminated the
inequities nor provided health care matched to the population's
health needs. Rather than need determining the allocation and
distribution of health services, which equity would require, we
find that services became distributed according to their prevaiUng
markets. The "commodification" of health services remains the
major cause of the inaccessibihty of health services to the poor

Epilogue I 213

and a major factor in the distortion of care to the entire society.

Over the last three decades private heahh insurance and
pubUc assistance programs have narrowed the gaps between the
poor and nonpoor in their use of health services. Poor adults from
eighteen to sixty-four years old now make slightly more visits to a
physician on the average than do nonpoor adults. However, the
poor at all ages receive less care relative to their need for medical
care. The disparity between need and what's received is especial-
ly great for children.^'

The reasons for these class differences are not difficult to find.
First, many physicians do not accept Medicaid patients because
Medicaid programs, which are administered by the states within
federal guidelines, pay less than doctors are used to getting from
their privately insured patients. In California, only about a third
of the state's obstetricians and gynecologists participate in the
Medicaid program, leaving nearly a third of the state's fifty-eight
counties without a single obstetrician or gynecologist to serve
Medicaid women. "^^ Second, white physicians and dentists gener-
ally do not locate their offices in poor or minority communities.^^
Third, as of 1971 nearly half the country's 35.5 million people
officially defined as poor had no Medicaid coverage. "^^

Health insurance itself is distributed in part according to the
class structure. Today 90 percent of all Americans have some
form of health insurance, three-fourths of them from private
insurance plans. In general, however, the most comprehensive
health insurance is available to persons in higher paying occupa-
tions and in the dominant sectors of the economy, which are more
unionized and can more easily pass along the costs of health
insurance to consumers. In 1974 some 60 percent of the employed
poor had no health insurance at all, and fewer than 10 percent
were insured for nonhospital services. "^^

While the growth of private health insurance and government
third-party payment programs helped reduce the inequities, they
do not cover all people or all health services equally well. In 1977
sixty-one cents of each dollar spent on personal health care
services were paid by third-party payment plans, leaving consum-
ers to pay thirty-nine cents of each dollar out of their own
pockets. Third-party payers covered more than 90 percent of the
cost of hospital care, but only 61 percent of physician fees and
even less for drugs and other commodities.

44

214 I Epilogue

Thus, even with the government subsidizing medical care for
the poor, the production and sale of medical care as commodities
are still distributed according to the class structure of the society
rather than on the basis of need. However, those at the bottom of
the class structure have not been the only ones to suffer under this
market economy.

The market system has also distorted the character and supply
of medical care for most of the population. The relatively
complete private and public third-party coverage of hospital care
has encouraged hospitalization for diagnostic and therapeutic
procedures that could be done more safely and inexpensively
outside hospitals — or avoided altogether.

Most surgery in the United States is done on a fee-for-service
basis. Doctors get paid high surgical fees for the operations they
perform, not for those cases in which they decide surgery is
unnecessary. As Dr. Charles Lewis has observed, "Patient
admissions for surgery expand to fill beds, operating suites, and
surgeons' time.'"*^ The United States has twice the ratio of
full-time surgeons to its population as England and Wales — and
twice as high rates of surgery. "^^ A congressional report estimated
that in 1974 approximately 2.4 million unnecessary operations
were performed in this country, resulting in 11,900 avoidable
deaths and a cost of $3.9 billion.'*''

Nationally, Medicaid patients have become a major source of
revenue for "underemployed" surgeons and underutilized hospi-
tal facilities. Medicaid recipients undergo surgery at twice the
rate of the general population and for some elective operations
(that is, for conditions that are not life-threatening) the difference
is even greater.'** Many well-insured persons — whether they be
privately insured members of the working class and middle class
or government-subsidized members of the poor and near-poor
strata — have been victimized by excessive care just as the poor
have historically been victimized by being priced out of adequate
medical care.

Physicians have concentrated themselves in specialties and
locations where they can take best advantage of the market for
their services. Because physicians have such a strong influence on
the demand for their services, large numbers of doctors in even a
relatively small but affluent area make an exceptionally fine living
by ordering enormous numbers of diagnostic and therapeutic

Epilogue I 215

procedures which they either perform or evaluate. Their market
in the past rehed mainly on the middle and upper classes, and
because of the financial and bureaucratic constraints of Medicaid,
doctors are still attracted more to the shrinking but well-off areas
of big cities and the expanding suburbs than to poor and
working-class areas. While affluent areas of Chicago average 210
physicians per 100,000 persons, poverty areas have sixteen
doctors per 100,000 — one-eighth as many physicians to popula-
tion. Similarly, Mississippi has only a third as many doctors as
New York state's abundant average of 244 per 100,000."^^

Physicians have also abandoned primary care practice for
more lucrative and prestigious specialties. General practitioners,
who in 1963 comprised nearly 28 percent of the country's
nonfederal physicians, by 1973 represented less than 18 percent
of the total. If we add to these GPs those specialists whose
practices are mainly focused on primary care — those in internal
medicine, pediatrics, gynecology, and family practice — still less
than half of all U.S. physicians are involved in primary care. By
contrast, prepaid group practices average 69 percent of their
physicians in primary care and the British National Health
Service includes 74 percent. This leaves the United States with
only sixty primary care physicians per 100,000 population, far
below the ratio of 133 such doctors per 100,000 persons recom-
mended as necessary to provide adequate primary care.^°

Since the turn of the century, the generalist and primary care
have taken a back seat to specialized practice and sometimes even
a career in medical research. The countryside, with its limited
market for specialty services and its isolation from centers of
technological medicine, cannot compete with more densely
populated urban areas with their hospitals linked to research-
oriented medical schools. Rural areas were of no interest to
modern physicians, and the urban poor were of interest only
when they served as research or teaching material. The techno-
logical imperative in medicine combined with the market organi-
zation of medical care to divert physicians from areas and types of
services in which they were most needed to those that were most
interesting, profitable, and professionally rewarding to them. In
sum, the private medical market has remained a major contradic-
tion in efforts to provide an accessible system of medicine geared
to the needs of the population.

216 I Epilogue

NATIONAL HEALTH INSURANCE:
MORE OF THE SAME

It can be stated as almost a certainty that national health
insurance in the United States will continue to promote capital-
intensive medical care in a market system. Each major medical
interest group is represented by a bill in Congress. The AMA, the
insurance industry, and the American Hospital Association have
all submitted bills that would favor their members. The AFL-CIO
and most bureaucratic professionals support the successive bills
sponsored by Senator Edward Kennedy. The Kennedy bills
would go farther than other national health insurance bills in
providing comprehensive and accessible care. Some versions of
the bill would even eliminate any administrative or third-party
role for insurance companies. All versions include an incentive
payment system to encourage physicians to join prepaid group
practices. While the Kennedy proposals would weaken the
financial base of fee-for-service medicine, none of them would
eHminate it nor would they eliminate the professional control of
hospitals and medical schools.

Only one proposal now under consideration would radically
alter the commodity system of medical care. The Health Service
Act, a bill sponsored by Representative Ronald Dellums, would
create a national health service that would employ physicians and
all other personnel on a salaried basis, take over the nation's
hospitals, control the production of health workers in medical
schools and other training programs, eliminate insurance compa-
nies from health care, and reduce the hierarchy of power among
health workers by subordinating all policy to community-based
boards. The Dellums bill would effectively transform the com-
modity production of medical care into noncommodity "social
production." Were the Dellums proposal implemented, it would
give the United States one of the most advanced health care
systems in the world, surpassing the most progressive systems in
Western Europe and perhaps equaling the organizational ration-
ality and public service character of health care in many socialist
countries. The Dellums bill is supported by a small proportion of
bureaucratic professionals, some of whom are leaders of the
American Public Health Association, and by left-of-center

Epilogue I 217

political groups. So thoroughly does it assault every vested
interest in health care and the ideological tenets of capitalist
society that it is a virtual certainty that the Dellums bill will not
see the light of legislative victory in the near future. Nevertheless,
it may serve as a model for those who want to reform the U.S.
medical care system.

The more far-reaching of the Kennedy bills are also unlikely
to win congressional approval. Their attacks on the interests of
the AMA, the best-financed lobby in the country, and the
insurance industry, not only a powerful lobby but a controlling
force in the nation's economy as well, make their legislative
future very dim. The other bills submitted by medical interest
groups will also fail because they too narrowly support the
interests of one sector of the industry. Instead, an administra-
tion-sponsored bill will become the foundation of national health
legislation, with amendments and revisions made to accommo-
date the more powerful interest groups that have entered the
fray.

The legislation that emerges from this process will undoubted-
ly favor the medical market and enhance the capital-intensive
sector of the system. It is hkely that whatever plan is adopted will
convert additional services that are now provided by the govern-
ment into commodities that can be bought and sold on the private
market. ^^ The insurance system will organize the collection and
payment of private funds into this commodity system with federal
tax dollars subsidizing only those who are priced out of the
medical market, thereby increasing the access of those groups to
medical care. While national health insurance will probably
encourage a slight redistribution of physicians, geographically
and between specialties and primary care, it will not break up the
power of interest groups and their manipulation of the medical
market to their advantages. It is likely that national health
insurance will push doctors toward prepaid group practice at a
slightly faster rate, and it will strengthen the control of most
dominant interest groups — especially the hospitals, medical
schools, insurance companies, and drug and medical supply
industries. More regulation will be developed to restrain infla-
tionary forces, somewhat protecting the interests of the State,
and to prevent the competitive interests of each segment from
destroying the medical care system they share. In other words.

218 I Epilogue

through national heahh insurance, the State will intensify the
capital-intensive commodity production of medical care and
rationalize the medical system in ways that further the common
interests of the system's dominant members. If this sounds
familiar, it should. National health insurance essentially promises
to give us more of the same.

Given the present size and importance of the medical
commodity sector and the absence of militant demands from the
underclasses, the State will continue to develop the role it has
increasingly taken over from foundations since World War II. It
will protect and promote a medical care system that is compatible
with corporate capitalist society's economic and political
organization — not only in the organization of medical care, but in
its content as well.

TECHNOLOGICAL MEDICINE

After World War II, the State rapidly replaced foundations as
the major source of financial support and direction in medical
research and education, just as it did in medical care. As the
remainder of this chapter will demonstrate, the State, like
foundations and wealthy individuals before it, continued to
promote and develop a narrowly technical and ideologically
conservative type of medicine — despite the overwhelming evi-
dence that broad factors in the physical and social environment
have at least as great an impact on health status as the
microbiological factors that receive most of the attention.

SCIENTIFIC MEDICINE: BELIEFS AND REALITY

Nearly all of us turn to medicine when we are sick. Whether
the healer is called a shaman, a witchdoctor, a priest, a feldsher,
or a physician, we all seek someone in whom to place our
confidence, someone we believe will make us well. Early in the
nineteenth century, most Americans relied on lay healers. By the
middle or latter part of that century, most Americans turned to
physicians, who were being prodigiously produced in mush-
rooming medical schools throughout the land. At the time, one
could choose the particular medical theory one wanted in a
physician — from homeopathy to orthodox or "allopathic" medi-

Epilogue I 219

cine — or the particular type of healer — from herbal traditions
to Christian Science. Not until the last two decades of the last
century were there any significant number of physicians who prac-
ticed what they called "scientific" medicine, meaning a medical
practice based on principles continuously being developed and
refined by the analytic biological and physical sciences.

Today most of us look to doctors and hospitals and surgery
and drugs to cure us of every ill. We want solace, and, therefore,
we expect it. The medical profession has, of course, encouraged
such beliefs through its campaigns to increase the confidence of
the populace (described in Chapter 2). Other medical interest
groups, Uke the American Cancer Society and the National
Cancer Institute, have joined in the campaign for public confi-
dence, frequently hosting briefing sessions for newspapers'
science and medical writers to learn about the "latest advances"
in cancer treatment. We have come to credit scientific, technolog-
ical medicine with having reduced the enormously high death
rates of past centuries and with being effective against most
disease and suffering in our time.^^ Yet such past successes and
current prowess are greatly exaggerated.

LIFE, DEATH, AND MEDICINE

THE HISTORICAL RECORD

Historical epidemiological evidence overwhelmingly supports
the conclusion that medical science has played a relatively small
role in reducing morbidity and mortality. Thomas McKeown^^
argues very convincingly that improved health and the great
decHne in Western Europe's total death rate from the eighteenth
century to the present were due to four factors. First, nutrition
improved because food supplies increased from the early eigh-
teenth century, due initially to the reorganization of agriculture
rather than improved chemical or mechanical technology. Sec-
ond, environmental sanitation measures — cleaning up the accu-
mulated filth of the cities, assuring uncontaminated water sup-
phes, and so forth — instituted by the late nineteenth century
added to improved nutrition and further reduced mortality,
particularly of children. These measures were well underway by
the middle of the century, before either the concept of specific

220 I Epilogue

causes of disease or the germ theory was widely accepted. Third,
these improvements in the standard of Hving caused a substantial
increase in population, which would have overrun the gains in
health if birth rates and family size had not soon sharply declined.
Finally, specific preventive and therapeutic medical measures
gradually introduced in the twentieth century sUghtly accelerated
the already substantial decHne in mortality and also improved
physical health. While science greatly extended the original
nontechnological advances in agriculture, hygiene, and birth
control, the contribution of medical science to the overall
reduction in death rates and improved health was relatively quite
small.

In the great majority of cases the toll of the major killing
diseases of the nineteenth century decHned dramatically before
the discovery of medical cures and even immunization. Tubercu-
losis, the Great White Plague, was one of the dread diseases of
the nineteenth century, kilhng 500 people per 100,000 population
at midcentury and 200 people per 100,000 in 1900. By 1967 the
U.S. rate had dropped to three deaths per 100,000. This
tremendous decline was only slightly affected by the introduction
of collapse therapy in the 1930s and chemotherapy in the 1950s. ^"^
Similarly, for England and Wales John Powles shows that overall
mortality declined over the last hundred years well in advance of
specific immunizations and therapies."

Rene Dubos, the microbiologist formerly with the Rockefel-
ler Institute, succinctly summed up the historical record. "The
tide of infectious and nutritional diseases was rapidly receding
when the laboratory scientist moved into action at the end of the
past century," Dubos wrote in Mirage of Health. "In reahty," he
observed, "the monstrous specter of infection had become but an
enfeebled shadow of its former self by the time serums, vaccines,
and drugs became available to combat microbes.""

Improvements in general living and working conditions as
well as sanitation, all brought about by labor struggles and social
reform movements, are most responsible for improved health
status. Improved housing, working conditions, and nutrition —
not medical science — reduced TB's fearsome death toll. Re-
sponding to riots and insurrections as well as the pitiable living
conditions of the poor and working classes in Western Europe
and North America, nineteenth-century reformers brought dra-

Epilogue I 221

matic declines in mortality without the benefit of even the germ
theory.^''

Children have benefited the most from these changes. The
average baby born in 1900 could have expected to live only
forty-seven years. A baby born in 1973 can expect to live more
than seventy-one years. Most of this increased life expectancy at
birth has been due to a sharp decline in infants' and young
children's deaths from infectious diseases. At the turn of the
century young children succumbed to influenza, pneumonia,
diarrhea, scarlet fever, diphtheria, whooping cough, and measles.
By 1975 the infant death rate had fallen to sixteen per 1,000 live
births — less than one-ninth the rate in 1900. And the death rates
of young children have similarly dechned.^^ Improved housing,
nutrition, water supplies and waste disposal, pasteurization of
milk, and the virtual elimination of child labor (except for
migrant farm workers) drastically cut the spread of infectious
diseases and enabled children's bodies to resist them.

LIFE, DEATH, AND MEDICINE TODAY

The physical and social environments are just as important in
determining disease and death rates today as they were historical-
ly, despite the fact that "degenerative" diseases, such as heart
disease, cancer, and stroke, have replaced most of the infectious
diseases as leading causes of death.

Infant death rates are still strongly influenced by environmen-
tal factors. Twelve countries — Sweden, East Germany, and
England among them — have lower infant death rates than the
United States. Within the United States an infant born to a black
mother with eight years of schooling or less is three times as likely
to die before its first birthday as a baby born to a white
college-educated mother. Although white and black infant death
rates have decreased in parallel through most of this century, the
death rate for black infants has remained consistently about twice
the rate for white babies. And a baby born into a poor family,
white or black, is much more likely to die than if he or she were
born into a nonpoor family. ^^

Indeed, a person who is poor or nonwhite is more likely to die
at every age. Nonwhite children die at twice the rate of white
children. Up to the age of sixty-five, nonwhite male death rates
exceed white male death rates by 40 to 95 percent, and nonwhite

222 I Epilogue

females die at more than twice the rate of white females in most
age groups.*" The probability of being disabled (temporarily or
permanently) is negatively related to income and education, but
positively related to being black.*' The more privileged your
class, race, education, and occupation, the less likely you are to
get sick or die at each age.*^ As epidemiologist Warren Winkel-
stein put it, poverty "remains among the most powerful determi-
nants of altered health status and clinical disease today. It may
well be that elimination of poverty in and of itself would
drastically alter the health status of the population in a favorable
direction.""

Environmental and occupational pollutants are also major
determinants of disease and death rates. Even "normal" levels of
air pollution have been associated with increased rates of disease.
Air pollution causes temporary deterioration of lung function and
increased frequency of lower respiratory tract infections in
children, in whom smoking and occupational dust exposures are
assumed to be minimal. Air pollution is also associated with lung,
stomach, and other forms of cancer, as well as chronic bronchitis
and asthma.*'^

More than 14,000 workers are killed each year in work
accidents, and between 2.5 million and 5.6 miUion workers suf-
fer temporarily or permanently disabling injuries on the job.
Occupation-related diseases are estimated to kill well over
100,000 persons each year." Even the president of the Blue Cross
Association has estimated that "31 percent of workers' health
problems are caused by factors in their environment."**

Social relations — the patterned ways in which individuals
relate to one another in society — also have a broad and dramatic
impact on how healthy people are and how long they live.
Hypertension, or high blood pressure, is associated with the
stresses of moving to or living in industrialized, urban society; it is
also related to working at high-pressure jobs and to being poor or
black.*'' The poor and racial minorities have higher rates of
alcoholism, mental illness, and homicide, and nonwhites at every
age die at rates 40 to 100 percent higher than those of whites.
From birth to old age, males have higher rates of death than
females, including death from many stress-related diseases, such
as heart attacks and strokes, and from many nondisease causes of
death, such as auto accidents, work accidents, homicides, and

Epilogue I 223

suicides/* Even whether labor is aUenated or satisfying is related
to life expectancy. A Department of Health, Education, and
Welfare task force reported that "in an impressive 15-year study
of aging, the strongest predictor of longevity was work satisfac-
tion."^^ Clearly, people's social roles and their positions in the
social structure have a major impact on their health.

Health and disease are thus determined by a combination of
factors. Genetic inheritance is one conditioning factor, and the
social, economic, and physical environment into which people are
born and in which they must live are other critical factors. These
factors determine the person's receptivity to disease as an
unwitting "host." Whether a person remains healthy or gets sick
is determined by inheritance, environment, and external "in-
sults" to the person — bacteria and viruses, chemical and physical
assaults on the body, social and emotional assaults.

Technological intervention in this process is very limited.
Robert Haggerty, a nationally respected pediatrician, recounts
some of the limitations of children's medicine in the 1970s:

We do not know how to prevent or treat effectively most of the
major killing disorders of childhood in the United States. . . . The
state of knowledge about acute and chronic conditions that usually
do not kill but impair function for short or long periods is not much
better. There is little we can now do to prevent or treat specifically
most acute respiratory infections or chronic handicapping condi-
tions.'^

Efforts to improve medical care in very poor communities
have had only a slight impact on people's health. A well-known
project that brought advanced primary care to a Navajo commu-
nity succeeded in reducing the recurrence of active tuberculosis
and the prevalence of infections of the middle ear but had little or
no effect on the pneumonia-diarrhea complex which continued as
the biggest single cause of illness and death as it had throughout
the country up to half a century ago. By the end of the ex-
periment the infant mortality rate for the community remained
about three times the national average.''^ Other experiments in
the United States and underdeveloped countries have had similar
results.''^

These sobering observations of the limits of medicine and the
importance of the environment should reduce our enthusiasm for

224 I Epilogue

turning to medical science and physicians to cure all our ills. But
we need not become "therapeutic nihilists"" in the process.
While we reject the popular mythology that cloaks medicine in
robes of omniscience, while we reject the unquestioning assump-
tion that technology can solve all our health problems, we must
recognize the advances and considerable value of modern med-
icine. Until the 1930s all but a few drugs were palliatives, at
best relieving the symptoms of a disease. Sulfonamides were
developed in the 1930s, penicilHn in the 1940s, and other
antibiotics in the 1950s. All were major additions to the arsenal of
physicians in the long-anticipated "war against disease." The
most rapid development of technical advances in medicine
occurred from the late 1930s, accelerated during and after the war
in the 1940s, and peaked in the 1950s.

Only some medical care, however, has had a significant
positive impact on the health status of the population. Campaigns
to immunize the population with polio vaccines, introduced in the
1950s, have reduced one of the most dread childhood diseases
from 18,000 cases in 1954 to only six in 1975. Rubella (or
"German measles"), which in pregnant women can cause devas-
tating congenital defects in their offspring, was reduced from an
average of more than 47,000 cases a year before widespread use
of the vaccine to 16,343 cases in 1975, following even hmited
immunization of the population. '''*

Good maternal health services — including prenatal and ma-
ternal medical care and coordinated social services — provided to
the entire population could materially reduce infant mortality
rates. David Kessner and other researchers, who carefully
studied New York City births in 1968, concluded that adequate
maternal health services provided to all women in the city would
have reduced infant mortahty there by one-third. The percentage
of low-birth-weight infants and infant deaths both decreased as
the adequacy of maternal health services increased, within
each racial, socioeconomic, social-risk, and medical-risk group.
Among college-educated mothers, the infants of those with
inadequate care were twice as likely to die as the babies of those
with adequate care. Among black college-educated mothers, the
infant death rate for those with inadequate maternal care was six
times as great as the rate for those with adequate care.''^ As
valuable as good maternal care is, however, one-quarter of the

Epilogue I 225

substantial decline in the infant mortality rate in the late 1960s is
accounted for by women giving birth at lower risk ages (mainly in
their twenties) and having fewer children.^**

Thus, comprehensive health services can have a limited but
positive impact on health status. Some vaccines have substantially
reduced infectious disease and death rates, although historically
most have simply accelerated already falling rates. Antibiotics
and sulfa drugs have also reduced disability and death from
infectious diseases. Recently developed antibiotics have greatly
reduced the isolation and convalescence of TB patients. Ade-
quate maternal care can lower infant mortality rates although
most of the decHne has been and is still due to improvements
in environmental conditions and patterns of child-bearing. In
general, comprehensive primary medical care can help limit the
progress of disease and help restore a sick or injured child or
adult to healthy development and functioning. When distributed
throughout the population, such care can contribute to improving
the general health status of that population. When combined with
social reforms— particularly ones that would eliminate the inequi-
ties of class, the brutality of racism, and the destruction of the
physical environment — good technological medical care and sup-
portive personal and social services can reduce the burden of
disease an individual, a family, or a society must bear. From the
Progressive era to the present, however, foundation- and gov-
ernment-sponsored medical research and medical care have been
narrowly technological and ideologically conservative.

TAPPING THE STATE TREASURY

Up to World War II foundations were the leading force,
besides the medical profession, shaping the direction of medical
education and research and, ultimately, medical theory and
practice. By 1940 the Rockefeller philanthropies alone had
contributed more than $161 million to medical education and
medical research.''''

Until World War II the federal government's support for
medical research and education was minor. In 1938 the Public
Health Service's research budget amounted to only $2.8 million.
In order to develop and apply medical research to the country's
war needs, however, the Committee on Medical Research was set

226 I Epilogue

up in 1941 in the new Office of Scientific Research and
Development. By 1944 the committee had received $15 milHon to
allocate to medical research activities.''*

After the war federal support for medical education and
research blossomed. The AMA's opposition to direct financial
aid for medical education was circumvented by channeling
Hill-Burton funds to teaching hospitals and turning on the spigot
of federal support for medical research, both of which the AMA
approved. The National Institutes of Health became the major
single source of medical research money. Its research budget
doubled from $28 million in 1950 to $60 million in 1955, and
doubled again every two or three years up to 1963. By 1975 total
federal health research expenditures reached $2.8 billion, sixty
cents out of every dollar spent by all sources on health research.
While the federal government's expenditures increased more
than thirty-six times in this period, philanthropy's contributions
increased only six times. ''^

What was responsible for this astronomical increase in State
support for technological medicine? Three sets of interests
benefited from this emphasis on and funding of technological
medicine — the academic medical profession, the corporate class
as a whole, and corporate and medical interests that profit from
medical technology. It was largely these groups that opened and
sustained the pipeline from the federal treasury to medical
research and technological development.

A "SUPERACADEMIC GENERAL STAFF"

First, an influential medical research elite has grown up
around medical schools, universities, private research laborato-
ries, and teaching hospitals and clinics. Medical schools, howev-
er, have been the main beneficiaries of the foundation and
government largess for research, receiving the largest share of the
money and having the greatest influence in the direction and
organization of medical research. Since World War II medical
school research funds have increased faster than operating
income. By 1953, research grants accounted for more than a
fourth of total U.S. medical school income. Federal support for
medical school operating and research expenses continued to
grow, topping $1.4 billion in 1973, most of it in research

Epilogue I 227

subsidies. By the late seventies about sixty cents of every dollar
spent by medical schools were provided by the federal govern-
ment, three times its share in 1950.*^

The ranks of full-time researchers and teachers among
physicians swelled to match the availability of funds. The
government, Uke the Rockefeller philanthropies under Frederick
T. Gates, encouraged the expansion of full-time clinical fac-
ulty—from 2,200 in 1950 to 24,000 in 1973, a 1,100 percent
increase! Doctors engaged full-time in medical teaching or
research increased from less than 2 percent of all physicians in
1950 to nearly 5 percent in 1973. «^

The bonanza of federal dollars bestowed on medical schools
since World War II fragmented them into collections of virtually
autonomous departments. Departments and institutes of full-
time faculty and researchers grew like mushrooms in response to
one or another funding program. Empires were built by promi-
nent faculty members who seemed to have a direct line to the
National Institutes of Health. Medical school and teaching
hospital administrators, wanting to expand their own domains of
facilities and staff, courted foundation and government officials
responsible for doling out research funds as well as the faculty
who attract the grants and contracts. Faculty members who
excelled at grantsmanship, rather than those who were the best
teachers, were favored with money and prestige, and became
models for medical students.*^ The situation remains unchanged
today.

Prominent members of this academic medical ehte not only
control the considerable sums of research money that they
receive from outside, or extramural, sources; they also have a
major role in determining who else will receive such funds.
Moving easily among medical schools, institutes, foundations,
and government agencies, this national academic elite has be-
come a formidable interest group. Even by 1927 Hans Zinsser
complained that the "guidance of medical education is to a
considerable extent passing out of the hands of the universities"
and into those of a "superacademic general staff. "*^

Following the dictates of their training, their intellectual and
practical competence, and their material interests, this academic
medical lobby has promoted technological and curative medical
research that has focused largely on hospital and medical school

228 I Epilogue

clinic patients. They encourage the appropriation of money for
health research, and they shape the specific research directions
and programs for which money is given.

But they and their institutions are dependent on outside
sources for both capital and operating expenses, and they tend to
be very responsive to agencies that foot their bills. They have
been supported by the larger medical profession which benefits
from the production of knowledge and technique (some of the
commodities of medical practice), but more fundamental support
comes from outside the health professions. That support depends
on the interests and programs of this dependent group coinciding
with the interests and strategies of economically and politically
more powerful groups. At first, foundations and then the federal
government provided that financial support and exercised the
control that goes with it, just as the AMA's Journal had feared
and warned the profession against as early as 1901.**

THE CORPORATE CLASS

As in the organization of medical care, foundation and
government programs in medical research represent the interests
of the corporate sector of society. From the founding of the
Rockefeller Institute for Medical Research in 1901 to the present
time, substantial sums of corporate wealth have supported
medical science and its technological applications. In 1975
foundations contributed $64 milHon, mainly income from their
corporate investments, to health research while private industry
itself spent $1,322 million on medical research and develop-
ment.*^ Even more important has been the strong political
support by foundation and corporate leaders for increasing
appropriations from the vast federal treasury. Private wealth
accounts for only a third of national health research expenditures,
but it has been influential in generating the other two-thirds from
the State.

The reasons for this support include the same considerations
that led to the founding of the Rockefeller Institute. As we found
in Chapter 3, Gates and other members of the corporate class
embraced scientific medicine because it supported their political
and economic struggles. Technological medicine provides the
corporate class with a compatible world view, an effective

Epilogue I 229

technique, a supportive cultural tool, and a focus on the disease
process within the body that provides a convenient diversion from
the health-damaging conditions in which people live and work.

Continuing its earlier policies, the Rockefeller Foundation
spearheaded efforts in the 1930s to develop a scientific biological
perspective in medicine and to integrate chemistry and physics
with biology. The Rockefeller, Macy, Milbank, and Ford philan-
thropies also generously supported the development of research
into mental illness, almost exclusively focused on physiological
factors with a little behavioral research.*^

Like the foundations and individual capitalists earher in the
century, federal health research has focused on the narrowly
technical components of disease and death rather than on the
broader economic and physical environments so central to the
population's health status. Cancer research is a prominent but
typical example. Throughout its existence since 1937, the Nation-
al Cancer Institute (NCI) has sought the key to understanding the
etiology, cure, and prevention of cancer largely in microbiologi-
cal research. In 1971 the Nixon administration launched a grand
"war on cancer," the second leading cause of death, and gave the
NCI a hefty 62 percent boost in its appropriations for the next
year, the biggest since a 90 percent increase it received in 1957.
By 1977 the NCI's annual budget had grown to $815 million —
three and a half times the pre-"war" level.*''

Neither the National Cancer Institute nor the American
Cancer Society has shown much interest in investigating the
environmental contribution to cancer. A committee of the NCI's
National Advisory Cancer Board expressed its "astonishment"
that the National Cancer Program allocated only 10 percent of its
budget to this area. In 1975 the NCI expanded its environmental
carcinogens program to $100 million, an impressive sum except
that it is only 17 percent of the NCI's budget for the year. This
miserly proportion devoted to environmental causes of cancer
seems especially ironic because NCI director Frank J. Rauscher,
Jr., publicly stated on several occasions the widely substantiated
view that up to 90 percent of all cancers originate in the
environment. According to federal health officials, epidemiologi-
cal evidence demonstrates that at least 20 percent — and perhaps
40 percent — of all cancer cases are caused by occupational
carcinogens, the most neglected area of environmental cancer
research.*®

230 I Epilogue

The more dominant lines of research focus on possible viral
causes, hereditary factors, and immunological defenses in the
etiology of cancer. The so far unproductive search for a viral
origin for human cancer cost three-quarters of a billion dollars by
1977. This and other lines of microbiological research have
contributed only marginally to improving survival rates for most
cancer victims. Rausher boasted in 1974, "The 5-year survival
rate for cancer patients in the 1930s was about 1 in 5. Today, the
figure is 1 in 3." However, Daniel Greenberg notes, "virtually all
of this improvement was achieved prior to 1955, which, ironical-
ly, was when federal spending for cancer research began to
accelerate to its present level." Greenberg chalks up much of the
improvement in survival rates through the midfifties to the
postwar introduction of antibiotics and blood transfusions that
reduced the death toll due to cancer surgery. "It wasn't that more
patients were surviving cancer^'' Greenberg asserts, "rather, they
were surviving cancer operations that previously killed them." In
Greenberg's view the contributions of chemotherapy, radiation
therapy, and new surgical techniques have been negligible. ^^

Typified by the federal cancer research program, lavish funds
are available for microbiological investigations of many diseases,
but relatively scant support is provided for research on occupa-
tional and other environmental causes. At most, one-sixth of all
federal health research dollars in 1977 were spent on environmen-
tal factors. One out of every five working coal miners in the
United States is a victim of black lung disease (which kills 4,000
miners each year), and on the average one miner is killed every
other day in mine accidents. Yet the amount of money per miner
spent in the United States for studying ways to improve miners'
occupational health and safety is only one-twentieth of that spent
in the majority of European countries.'"

This neglect of occupational and environmental bases of
disease and death is not primarily due to conspiracy. The medical
profession is, as we have seen in previous chapters, tied to
the corporate class. Office-based physicians' median incomes
reached $63,000 in 1976, placing them in the top few percentiles
of the society's income structure. '^ Physicians in private practice
earn their money from a market system of medical commodities,
encouraging a conservative "free enterprise" political perspective
and a sympathy for other entrepreneurs in the capitalist system.

Epilogue I 231

Medical researchers may be free of the influence of the medical
commodity marketplace, but to win fame and fortune they must
obey the rules of the medical research funds "market." Their
dependence on foundation and government funding agencies
restricts the range of problems and methods they may investigate
and constrains their creative intellectual processes as well. The
malignant neglect of occupational and environmental, social, and
economic factors in medical research is thus due to the lopsided
financial support provided for narrow microbiological investiga-
tions, the financial and class interests of the medical profession,
mechanistic and reductionist medical theory, and the correspond-
ingly narrow technical training of physicians.

Underlying these largely institutional and class factors, how-
ever, are the deliberate policies of major corporate and political
institutions. Foundations, corporations, and government agen-
cies differ among themselves and over time in their financial and
political support for social versus technical perspectives in
medicine. But in the long run and at any time they overwhelming-
ly support technical perspectives that separate health problems
from their social and political contexts. Their policies reflect a
general corporate class concern that any excess sickness and
death not be attributed to the admitted inequahties of capitalist
society or to the organization of production that places profits
before environmental protection and workers' health. In addition
to this broad class interest in legitimation, however, a growing
interest group within the corporate class has a direct financial
stake in the dominance of technological medicine.

THE MEDICAL-INDUSTRIAL COMPLEX

The interests of doctors, hospitals, research scientists, and
medical industrial corporations all coincide in the promotion of
expensive medical technology. They have built a profitable
symbiotic relationship based on the commodity system of medical
care and society's cultural affinity and ideological support for
technological medicine.

A recent report of the congressional Office of Technology
Assessment showed how the introduction of new medical tech-
nologies creates or expands a market. Most of the risk capital is
supplied by the government although the profits derived from the
products of this research are taken by private industry. In 1975

232 / Epilogue

the federal government provided about $2.8 billion out of a total
of $4.6 billion spent on health research and development. State
and local governments picked up about 5 percent of the total, and
private nonprofit agencies gave another 5 percent. These public
and private funding agencies provided almost all the funds for
basic research, the fundamental laboratory and clinical science
work that develops new knowledge in medicine. The $1.3 billion
spent by private industry, together with a healthy chunk of
government money, went mainly for product development,
applying knowledge gained from basic research to the creation of
technologies that can be used in medical care.^^

Private industry not only controls the fourth of all this
research and development money it spends; it also determines
whether the knowledge generated by basic research will be made
available as new medical products. Since both kinds of decisions
are based on the expected profitability of any investment rather
than on the basis of medical need and safety, it is not surprising
that drugs and equipment of questionable usefulness and often
significant danger are produced and that other medically useful
products fail to be developed. ^^

Once a product or service is developed, the major medical
interest groups determine its market. The commodity's producers
extol its advantages and push for acceptance and sales. If the
drug, instrument, or procedure increases the technical effective-
ness of physicians, it is likely to be ordered by them. If it increases
the status or incomes of physicians, it is also likely to be used. If
its availability in a hospital is likely to attract physicians or
otherwise produce income, hospitals will want to buy it. If
third-party payers will foot the bill, it is a certain winner. The
growth of clinical laboratory testing illustrates the effectiveness of
these market forces.

Automated blood analyzers, first introduced in the 1950s and
perfected in the years since, make it possible to perform many
"extra" tests on a single sample of blood, at a low unit cost but at
a high aggregate cost. Physicians order increasing numbers of
tests which were previously considered unnecessary and which
are, to many analysts, not necessary "for even the most rigorous
medical practice." Physicians frequently fail to use the results of
tests they have ordered. As fears of malpractice suits increased,
doctors began expanding the limits of "defensive medicine,"

Epilogue I 233

ordering ever larger numbers of tests to protect themselves
against "litigious" patients. The growth of third-party payment
programs facihtated increased use of clinical laboratories, and
hospitals found it economically desirable to expand their labora-
tory capacities. Between the added fees doctors could charge, the
economic "necessity" that hospitals felt, the facihtation of
third-party payments, and the advertising of equipment and
supply companies, the number of chnical laboratory tests reached
5 billion in 1975 (an average of twenty-three tests for every
woman, man, and child in the country) and is increasing by 11
percent a year. Although automated laboratory equipment is
expensive — for example, the latest automated blood chemistry
analyzer (the SMAC 60) costs more than $250,000 — it represents
only a minute fraction of the costs generated by clinical laborato-
ry technology. The $375 million spent on laboratory instruments
in 1975 was only 2.5 percent of the $15 billion bill for clinical
laboratory testing, most of which went for space, supplies,
maintenance, personnel, and profits for the laboratories and
physicians.^'*

The cost of this and other medical technology in a commodity
medical care system is enormous and rising at essentially geomet-
ric rates. Medical technology is estimated to account for half the
increase in costs of hospital care from 1965 to 1974, a period in
which hospital expenditures tripled. ^^

In the days when Frederick T. Gates dreamed of medical
research laboratories unlocking nature's secrets, medical technol-
ogy was a fledgling business. Today the "medical-industrial
complex" is a huge business that sops up an increasing share of
national health expenditures for products and services that return
a handsome profit to manufacturing and sales companies,
researchers, hospitals, laboratories, and doctors. However, the
economic return to these interest groups and the political value of
technological medicine to the corporate class were not enough to
overcome the serious economic problems caused by medical
technology in a subsidized market economy.

TECHNOLOGY IN CRISIS

As hospitals increased their charges at more than twice the
rate of inflation in the rest of the economy, as health expenditures

234 I Epilogue

took a bigger and bigger bite of national resources and the federal
budget, as medical fringe benefits consumed more corporate
income and medical expenses cut into more and more of workers'
incomes; government, corporate, union, and consumer leaders
grew critical of the endless expansion of capital-intensive medi-
cine. Besides demanding regulation of hospital expansion and the
imposition of cost controls, these groups' political support for the
expansion of medical technology fell off sharply. The market
system's tendency to produce and absorb an inordinately expen-
sive medical technology forced an examination of the value of
that technology.

Dr. David Rogers, president of the giant Johnson Founda-
tion, whose wealth emanates from the medical supply business,
called for "technologic restraint. "^^ Anne Somers, usually an
advocate of the hospitals' interests, succinctly summarized the
case against unlimited expansion of technological medicine: "The
more advanced and the more effective the technology, the greater
the overall costs of health care."^''

By the midsixties support for continued growth of technologi-
cal medicine began to wither. Rapidly increasing health expendi-
tures and the well-documented role of medical technology in
pushing up those costs darkened the previously bright future for
medical research and its applications. The war in Vietnam was
competing for federal tax dollars while the anti-war movement
and the rapidly growing movement to protect what was left of the
environment undermined political support for indiscriminate
technological development. The virtual war in American cities in
the midsixties, whose demands were articulated by the civil rights
and black liberation movement, forced increasing appropriations
for improving inner city services, including medical care. The
combination of all these factors reduced political support for
technological medicine — and cut into medical research's share of
health expenditures. Federal appropriations for health research,
which had increased 745 percent between 1955 and 1965,
increased less than a fifth that much in the next ten years. ^^

Foundations and the government increased their support for
the study of medical care delivery problems. They supported
experiments and reforms that would either lower the costs of
medical care or improve access to low-technology primary care.
They also gave new life and prominence to an old medical

Epilogue I 235

ideology — one that justified clamping down on medical care
expenditures and provided a substitute for the legitimizing
functions performed by the increasingly discredited medical
technology.

BLAMING THE VICTIM: NEW PROMINENCE
FOR AN OLD IDEOLOGY

At first the criticisms of technological medicine focused on the
many systemic factors that increased its use. Medical economist
Victor Fuchs criticized the "technological imperative" in medi-
cine, the attitude that if something technological can be done for
a patient, it should be done.^' Fuchs attributed this accelerator
tendency to the training of physicians, the reimbursement
insurance system that encourages the use of costly services, drug
and medical supply companies pushing their products, and
pressure from patients.

Disenchantment with medicine's technical effectiveness, or
rather its ineffectiveness and its dangers, reinforced the attack on
medical technology that began with medicine's fiscal problems.
Doubts about all this emphasis on medical technology spread
from a small coterie of academic critics in the 1950s to the highest
policy circles of government and foundations in the 1970s. In the
latter half of the fifties, Rene Dubos^°° and a handful of other
observers were pointing out the futility of relying on medicine to
cure the ills created by social and physical environments. In the
seventies Jesuit priest and social philosopher Ivan IUich,^°^
Canadian Health and Welfare Minister Marc Lalonde,^"^ and
others ^°^ criticized medicine for the disease it breeds, for its
relatively small positive impact on health status and disease rates,
and for extending its domain of control to more and more of our
social and personal relations.

One outcome of this criticism was the belief that what doctors
and medical technology were doing badly, we could do better for
ourselves. Critics of medicine advocated individual "self-help" as
a source of liberation from professional and technological
control. Many of them, however, extended this position to
identify individuals as the greatest dangers to their own health. A
large-scale study of health behavior in CaUfornia supported the
view that a person's "lifestyle" is a powerful determinant of his or

236 / Epilogue

her health status. ^""^ Fuchs, ignoring contrary epidemiological
evidence, asserts that "the greatest potential for reducing coro-
nary disease, cancer, and the other major killers still lies in
altering personal behavior. "'"^ A host of other academic health
researchers and writers and members of the growing "holistic"
health movement fastened on the individual as the core of health
problems. ^°^ Perhaps the ultimate absurdity of this position
blames lead poisoning of young children in low-income neighbor-
hoods on maternal deprivation ^""^ and "permissive socialization of
oral behavior" ^°^ — instead of on landlords who fail to remove the
lead-based paint peeling from walls of their rental units and to
repaint with lead-free paint now required by law.

These arguments quickly caught the attention of major health
policy makers. Walter McNerney, president of the Blue Cross
Association, argues.

We must stop throwing an array of technological processes and
systems at lifestyle problems and stop equating more health services
with better health. . . . people must have the capability and the will
to take greater responsibility for their own health.

109

Technological medicine is becoming prohibitively expensive,
but victim blaming is cost-effective. "The cost of sloth, gluttony,
alcoholic intemperance, reckless driving, sexual frenzy, and
smoking have now become a national, not an individual, respon-
sibility, all justified as individual freedom," asserts Dr. John
Knowles, the influential president of the Rockefeller Foundation.
"But one man's or woman's freedom in health is now another
man's shackle in taxes and insurance premiums." Knowles sternly
warns that "the cost of individual irresponsibility in health has
become prohibitive. "'^° Fuchs attacks what he sees as "a
'resolute refusal' to admit that individuals have any responsibility
for their own distress. "''' And Leon Kass, denying that health or
health care is a ri^ht, proclaims that "health is a duty, that one
has an obhgation to preserve one's own good health." Kass, a
professor of medicine and bioethics, goes on to condemn
"excessive preoccupations with health" such as "when cancer
phobia leads to government regulations that unreasonably restrict
industrial activity or personal freedom.""^

Individual failure has long been used to explain why the poor
and racial minorities use many physician and dental health
services, especially preventive ones, less than more affluent

Epilogue I 237

groups do. Health professionals and their academic colleagues
often conclude that low utilization reflects inadequate knowledge
of the importance of preventive and early illness care and
insufficient motivation to use them.^^^ "Under-utilization" and
disapproved lifestyles are, in this view, individual failings which
can perhaps be remedied by educational programs — an opportun-
ity for professional intervention to teach the poor "correct"
health habits and the importance of health services.

Attitudes do influence health behavior, but there is substan-
tial evidence that when racial minorities and the poor have
accessible and comprehensive medical services, their utilization
rates are similar to those of the general population. '^"^ This
evidence supports the argument that the lower use of such health
services is the result of structural and functional problems in the
services themselves rather than disfunctions in the potential
users.

Victim blaming has been used not only to explain lower
utilization by the poor but as a way of decreasing the use of health
services by Medicaid recipients. In order to cut the escalating
costs of Medicaid programs, the Nixon administration and
conservative governors created barriers to the use of services.
Setting limits on physician and dentist visits, especially for
preventive care, and setting up bureaucratic delays for hospitali-
zation (such as requiring physicians to obtain prior authorization
before admitting a Medicaid patient to the hospital), the State
made the "beneficiaries" of its programs pay for the market
system's fiscal problems. ^'^ Similarly, Medicare patients have
been forced to pay higher deductibles and copayments in order to
encourage them to spend less on their care. With the recent
campaign of putting increasing responsibihty on the individual,
the working and middle classes, as well as the poor, are being
blamed for getting sick in the first place.

The prospects of national health insurance raised fears that
further socializing the costs of medical care would only esca-
late the "technological imperative." Rather than question the
decades-old policy of rationalizing the private medical market,
health policy makers focus instead on the individuals who dare to
succumb to the hazards of life in our society. Paying little more
than lip service to the need to do something about the physical
environment and social and economic conditions that are known
to breed disease, they settle on an ideological position that is less

238 I Epilogue

threatening to the capitalist society of which they are important
members. Technological medicine was proving a costly hardware
system whose legitimacy has been undermined. Victim blaming
is a cheap and ideologically safe software alternative.

However, the victim-blaming strategy is generating opposi-
tion. Some public health officials have spoken out against this
perspective. "For the vast majority of people in our society,"
argued C. Arden Miller as president of the American Public
Health Association, "the life circumstances leading to poor
health are not adopted as a matter of personal choice, but are
thrust upon people by the social and economic circumstances into
which they are born.""* Opposition is also developing in the
labor movement to screening workers for at-risk health habits
and "sensitivity" or "susceptibility" to occupational carcinogens,
and to the barring of fertile women from hazardous jobs in the
lead and chemical industries instead of eliminating the hazards
from the workplace."''

An alternative to victim blaming and narrowly technological
approaches to environmentally generated disease is an "ecologi-
cal" strategy. In this model, health workers analyze the different
factors that contribute to a health problem and, then, with the
people affected develop social and political, as well as medical-
technical, strategies for changing them."* Individually oriented
curative medicine is obviously needed because human beings are
not perfectly adapted to any physical or social environment. But
health care should do more than apply a band-aid to the wounds
created by disharmony between people and environment. Much
of this disharmony is the result of exploitation of the physical and
social environment for profit, a process in which cancer caused by
occupational and environmental pollution, high blood pressure
due to stress, and excessively high death rates related to poverty
and racism are considered "social costs" of production. However,
political pressure can be developed to change these conditions
and, ultimately, to reorganize production around social needs
rather than the private accumulation of capital.

CONCLUSION

American society is faced with a health system that is at once
expensive and incapable of serving the important health needs of

Epilogue I 239

the population. Despite many decades of efforts to make
medicine more effective and improve its accessibility, the system
seems to remain impervious to fundamental change. The reform
efforts, however, are themselves fundamentally flawed.

From the early Rockefeller medical philanthropies to the
opening of the federal treasury to the health sector, the major
strategy for making medicine more effective has been biomedical
research and the development of technological medicine. Techni-
cal advances have been very great, but the results have not been
distributed equitably, coordinated rationally with needed primary
care, or matched with support for improvements in the physical
and social environments. Technique has also increasingly re-
placed personal caring and emotional support in doctor-patient
relationships. As we have seen, these emphases have had only a
limited positive impact on the health of the population. The
persistence of such narrowly technical approaches is due to their
usefulness to powerful classes and interest groups. For members
of the corporate class, technological medicine has legitimized
their economic and political dominance by diverting attention
from the consequences of their control — that is, from such "social
costs" as class inequalities, domination based on race or sex,
occupational hazards, and environmental degradation. For the
medical profession, the knowledge generated by medical science
and the techniques of medical technology provided the basis for
physicians' claims to a monopoly of authority over the practice of
medicine. Over the last few decades medical technology has been
the foundation of a whole new industry, an interest group that
directly profits from the emphasis on technical approaches to
health problems. Technological medicine has benefited all these
groups, and they have, in turn, supported its expansion.

The Rockefeller philanthropies also began the long process of
rationalizing medical care. This campaign has been joined by
groups in and outside the health sector and has been increasingly
supported by the State over the last several decades. The political
power of the medical profession was strong enough to block early
efforts at subordinating all elements of the system into a
hierarchy of organizational authority. So pieces of the rationaliz-
ing strategy were implemented where there was least resistance.
Voluntary health insurance programs — private and later public
ones — were developed mainly around hospital care, financing the

240 I Epilogue

expansion of high technology medicine with the hospital at its
center. The rationalizing of the private medical market helped
the growth of the capital-intensive medical commodity sector,
which has a major stake in technological medicine. The private
control of this market, the emphasis on medical technology, and
the socializing of costs by third-party payers combined to make
expenditures soar, compounding government fiscal problems and
draining ever-increasing amounts of money from the economy.

Medicine's upper-class reformers, from Gates and his founda-
tion colleagues to present-day officials of the State, have been
unwilling to oppose the private market in its entirety, producing a
profound contradiction in their struggles to rationalize medicine.
They favored the development of the private market with
legislative and financial support in lieu of nationalizing medical
care. The present crisis is a result of this political-economic
process. It was an inevitable outcome only in that those who
shaped the system believed in, or at least accepted, the needs and
constraints of capitalist economic and social relations. If Gates
and subsequent foundation and government leaders in the field of
medicine had been committed to making health care serve the
needs of the majority population rather than the needs of
capitalism and the interests of the corporate class, a different
course would have been followed. Even today a comprehensive,
centrally planned nationalized health service could effectively
control cost and provide equal care for the whole population.
Health care could be more effective in improving health if its
research and action were directed at environmental conditions in
about the same proportion that those conditions contribute to
sickness and death.

But health policy makers cannot be counted on to make these
fundamental changes. As members of the corporate class or
identified with its interests, they believe, to paraphrase Charles
Wilson's audacious aphorism, "what's good for business is good
for America." Furthermore, the capitalist sector of medicine has
grown rich and powerful, bringing the economic and political
influence of insurance companies, banks, and industrial corpora-
tions into active support for retaining the private medical market.
National health insurance is supported because it will further
socialize the costs of medicine, but nationalizing medicine in a
national health service is unacceptable to the powerful private

Epilogue I 241

market forces and therefore is ignored by health pohcy makers.
Instead of overhauHng the medical system, they put the burden of
controlling costs on people who have been afflicted with disease
by restricting their access to services and demanding that they
improve their health by changing their behavior.

However, even a national health service would not necessarily
end medicine's role of legitimizing corporate capitalist society. It
would, if anything, enable these ideological functions to compete
less with the needs of the marketplace. Without the access
problems that remain in the present market system, the "heahng
ministration," as Gates called medicine, could bring individual-
focused, technical perspectives and methods to the health prob-
lems of the entire population.

Health care, potentially, has a great deal to offer. We
rightfully expect it to prevent sickness, diagnose our ills, relieve
our pains, and, when we are sick, return us to at least our usual
level of functioning. If it were not distorted by its character as a
commodity and by the ideological functions demanded of it,
health care might well be developed as we wish it would. It is
possible to make a health care system that effectively serves the
health needs of the majority classes rather than the economic and
political interests of its providers and the upper classes. It is
doubtful, however, that such a health care system can be realized
in a capitalist society, committed as it must be to maintaining the
primacy of capital accumulation. Nevertheless, the struggle for
that new health system may contribute to the larger struggle for a
new, more just economic and social order.

Notes

The Journal of the American Medical Association is abbreviated
throughout as JAMA.

INTRODUCTION

1. New York Times, April 26, 1977.

2. Ivan lUich, Medical Nemesis, The Expropriation of Health (New York:
Pantheon, 1976).

3. See, for example, Rene Dubos, Mirage of Health (Garden City, N.Y.: Anchor
Books, 1959); Marc Lalonde, A New Perspective on the Health of Canadians
(Ottawa: Government of Canada, 1974); A. L. Cochrane, Effectiveness and
Efficiency: Random Reflections on Health Services (London: Nuffield Provincial
Hospital Trust, 1972); Rick J. Carlson, The End of Medicine (New York: John
Wiley, 1975); Howard B. Waitzkin and Barbara Waterman, The Exploitation of
Illness in Capitalist Society (Indianapolis, Ind.: Bobbs-Merrill, 1974); and John
Ehrenreich, ed.. The Cultural Crisis of Modern Medicine (New York: Monthly
Review Press, 1978).

4. David Mechanic, The Growth of Bureaucratic Medicine (New York: John
Wiley, 1976), p. 42; and his Politics, Medicine, and Social Science (New York:
John Wiley, 1974), chap. 3.

5. Illich, Medical Nemesis, p. 211.

6. See the excellent critique of industrialism and technological determinism in
Robin Blackburn, "A Brief Guide to Bourgeois Ideology," in A. Cockbumand
R. Blackburn, eds.. Student Power (Baltimore: Penguin, 1969), pp. 163-213;
the brief discussion in David Noble's illuminating book, America by Design —
Science, Technology, and the Rise of Corporate Capitalism (New York: Knopf,
1977), especially the introduction; and Vicente Navarro's critique of industrial-
ism in his review of lUich's work, in Navarro, Medicine Under Capitalism (New
York: Prodist, 1976), pp. 103-31.

7. William Weinfield, "Income of Physicians, 1929-1949," Survey of Current
Business, 31 (July 1951), 11; and Maurice Leven, The Incomes of Physicians: An
Economic and Statistical Analysis, Committee on the Costs of Medical Care,
Publication no. 24 (Chicago: University of Chicago Press, 1932), p. 88.

8. Zachary Y. Dyckman, A Study of Physicians' Fees (Washington, D.C.:
President's Council on Wage and Price Stability, March 1978), pp. 74-75 ;Harris
polls reported in Newsweek, Dec. 10, 1973, p. 45, and New York Times, June
12, 1977, p. 55. See also Navarro, Medicine Under Capitalism, pp. 135-69.

9. On physician dominance, see Victor R. Fuchs, Who Shall Live? Health,

244 I Notes to Pages 6-19

Economics, and Social Choice (New York: Basic Books, 1974), chap. 3; Eliot
Freidson, Profession of Medicine: A Study of the Sociology of Applied
Knowledge (New York: Dodd, Mead and Co., 1970); and Barbara Ehrenrei-
chand John Ehrenreich, "Medicine and Social Control," in J. Ehrenreich, ed..
Cultural Crisis, pp. 39-79.

10. Herman M. Somers and Anne R. Somers, Doctors, Patients, and Health
Institutions: The Organization and Financing of Medical Care (Washington,
D.C.: Brookings Institution, 1961), p. 42; Physician Distribution and Medical
Licensure in the United States, 1974 (Chicago: AMA, 1975), p. 66; and Harry T.
Paxon, "Why Wesley Hall Ripped into the AMA Hierarchy," Medical Econ-
omics, Jan. 3, 1972, pp. 25-^2, 101.

11. Robert Alford, Health Care Politics: Ideological and Interest Group Barriers to
Reform (Chicago: University of Chicago Press, 1975).

12. Anne R. Somers, Health Care in Transition (Chicago: Hospital Research and
Educational Trust, 1971), chap. 3, presents the AHA p>oint of view.

CHAPTER 1

1. The best biography of Carnegie is Joseph Frazier Wall, Andrew Carnegie (New
York: Oxford University Press, 1970).

2. Of the numerous biographies of Rockefeller, I have relied mainly on Allan
Nevins, John D. Rockefeller: The Heroic Age of American Enterprise, 2 vols.
(New York: Charles Scribner's Sons, 1940); and Peter Collier and David
Horowitz, The Rockefellers: An American Dynasty (New York: Holt, Rinehart
and Winston, 1976), pp. 1-73. The former book is the most detailed, but the
latter puts his Hfe into perspective and examines it somewhat critically.

3. On the changing class structure resulting from industrialization during the
nineteenth century, see William Appleman Williams, The Contours of American
History (Cleveland: World Pubhshing Co., 1961); and Robert H. Wiebe, The
Search for Order, 1877-1920 (New York: Hill and Wang, 1967).

4. Williams, Contours, pp. 315, 333. See also Richard O. Boyer and Herbert M.
Morais, Labor's Untold Story, 3rd ed. (New York: United Electrical, Radio,
and Machine Workers of America, 1972).

5. John D. Rockefeller, Random Reminiscences of Men and Events (New York:
Doubleday, Page and Co., 1909), pp. 141^2.

6. Ibid., p. 158.

7. Quoted in Edward Chase Kirkland, Dream and Thought in the Business
Community, 1860-1900 (Chicago: Quadrangle Books, 1964; originally pub-
lished 1956), p. 165.

8. Hanna quote from M. A. Hanna to J. D. Rockefeller, Sept. 8, 1885,
Rockefeller Family Archives, record group 1. On Hanna's role in building
poUtical capitalism, see Williams, pp. 349, 360-62, 381. On the development of
close ties between the executive branch and private industry and finance, see
Gabriel Kolko, The Triumph of Conservatism: A Reinterpretation of American
History, 1900-1916 (Chicago: Quadrangle Books, 1967; originally published
1963); and on the further development of this corporate liberal program of
reforming government to serve the needs of monopolistic industry, see James
Weinstein, The Corporate Ideal in the Liberal State, 1900-1918 (Boston: Beacon
Press, 1968).

9. Correspondence between Hanna and Rockefeller, 1885 to 1892, Rockefeller
Family Archives, record group 1.

Notes to Pages 20-31 I 245

10. For a brief view of how the wealthiest Americans lived in this period and
complaints and defenses regarding their ostentation, see Kirkland, Dream and
Thought, chap. 2.

11. For an uncritical historical survey of philanthropy in the United States, see
Robert H. Bremner, American Philanthropy (Chicago: University of Chicago
Press, 1960); the Mather and Frankhn quotes are from pp. 12-17.

12. Ibid., pp. 96-99.

13. Richard Hofstadter, Social Darwinism in American Thought (Boston: Beacon
Press, 1955); quote from Spencer on p. 41.

14. See, for example, any of the Proceedings of the National Conference of Charities
and Correction for this period; Amos G. Warner, American Charities, rev. ed.
(New York: Thomas Y. Crowell, 1919; originally published 1894); and Frank D.
Watson, The Charity Organization Movement in the United States: A Study in
American Philanthropy (New York: Macmillan, 1922) — all representative of
this movement.

15. Edward T. Devine, "The Dominant Note of the Modern Philanthropy,"
Proceedings of the National Conference of Charities and Correction (1906), p. 3.

16. Warner, American Charities, pp. 28, 46-47.

17. Anthony Piatt, The Child Savers: The Invention of Delinquency (Chicago:
University of Chicago Press, 1969), pp. 35-36.

18. Quoted in Howard S. Miller, Dollars for Research: Science and Its Patrons in
Nineteenth-Century America (Seattle: University of Washington Press, 1970),
pp. 159-60.

19. Jane Addams, Twenty Years at Hull-House (New York: Signet/Macmillan,
1961; originally published 1910), p. 299; quoted in Piatt, Child Savers, pp.
96-97.

20. On the development of public schools, see Michael B. Katz, Class, Bureaucra-
cy, and Schools— The Illusion of Educational Change in America (New York:
Praeger Publishers, 1971); and Joel H. Spring, Education and the Rise of the
Corporate State (Boston: Beacon Press, 1972).

21. Hamilton A. Hill, Memoir of Abbott Lawrence (Boston: "Printed for Private
Distribution," 1883); p. 108.

22. Ibid., p. 109.

23. See Harry Braverman, Labor and Monopoly Capital: The Degradation of Work
in the Twentieth Century (New York: Monthly Review Press, 1974), pp. 125-37.

24. Miller, Dollars for Research, p. 7.

25. Ibid., pp. 3-8.

26. Merle Curti and Roderick Nash, Philanthropy in the Shaping of American
Higher Education (New Brunswick, N.J.: Rutgers University Press, 1965), pp.
70-72.

27. Ibid., pp. 69-70. See also Frederick Rudolph, The American College and
University: A History (New York: Vintage Books, 1965), pp. 222-31.

28. Curti and Nash, Philanthropy, pp. 64-65.

29. Elbert Vaughan Wills, The Growth of American Higher Education— Liberal,
Professional, and Technical (Phila.: Dorrance and Co., 1936), p. 147.

30. Curti and Nash, Philanthropy, p. 135.

31. Ibid., pp. 64-65, 112-14.

32. "Wealth," North American Review, 148 (June 1889), 653-64; and 149 (Dec.
1889), 682-98; reprinted in Andrew Carnegie, Gospel of Wealth and Other
Timely Essays (Cambridge, Mass.: Harvard University Press, 1962), pp. 14-49.

33. Quoted in Wall, Carnegie, pp. 812-13.

246 I Notes to Pages 31^3

34. For gifts given by Carnegie in his lifetime and bequeathed by him at his death,
see A Manual of the Public Benefactions of Andrew Carnegie (Washington,
D.C.: Carnegie Endowment for International Peace, 1919).

35. Wall, Carnegie, pp. 806-12.

36. Manual of the Public Benefactions.

37. The account of Rockefeller's life is taken from Nevins, Rockefeller; and Collier
and Horowitz, Rockefellers, pp. 1-73.

38. Quoted in Nevins, Rockefeller, II, 177.

39. Quoted in Collier and Horowitz, Rockefellers, p. 48.

40. A detailed and readable account of the development of the University of
Chicago is found in Nevins, Rockefeller, II, 191-227.

41. Ibid., 213-14.

42. Ibid., 213-14,627, 266.

43. Ibid., 269, 427; and Collier and Horowitz, Rockefellers, pp. 45-47.

44. Gates describes the meeting with Rockefeller in his Autobiography. At the time
this book was researched and written. Gates' autobiography was an unpublished
typescript in the Rockefeller Foundation Archives. It has since been published
as Chapters in My Life (New York: Free Press, 1977). I continue to use the
citation "Gates, Autobiography," referring to the typescript pages. Gates'
meeting with Rockefeller is also recounted in detail in Nevins, Rockefeller, II,
266-69.

45. Gates, Autobiography, p. 342; and quoted in Nevins, Rockefeller, II, 268.

46. Nevins, Rockefeller, II, 268.

47. Gates, Autobiography, pp. 342-45.

48. Rockefeller, Random Reminiscences, p. 116; Allan Nevins, A Study in Power:
John D. Rockefeller, Industrialist and Philanthropist (New York: Charles
Scribner's Sons, 1953), II, 197; and Gates, Autobiography, p. 366.

49. Nevins, Rockefeller, II, 274-81; and Rockefeller, Random Reminiscences, p.
117.

50. Nevins, Rockefeller, II, 279-81.

51. Ibid., 274; and Gates, Autobiography.

52. The only account of Gates' early life is in his Autobiography; it is summarized
with quotes in Nevins, Rockefeller, II, 269-72.

53. Nevins, Rockefeller, II, 272-73.

54. Memo, April 20, 1891, GEB files. Rockefeller Foundation Archives.

55. Nevins, Rockefeller, II, 282-85; and Gates, Autobiography, p. 375.

56. Gates, Autobiography, pp. 310-15; F. T. Gates to J. D. Rockefeller, June 12,
1916, and E. N. Gary to J. D. Rockefeller, May 4, 1909, both in Rockefeller
Family Archives, record group 2.

57. Quoted in B. C. Forbes, "How John D. Rockefeller Became America's
Foremost Organizer and Richest Man," Leslie's, Sept. 29, 1917. See also
Rockefeller, Random Reminiscences, p. 117.

58. Details of Junior's life are available in Collier and Horowitz, Rockefellers, pp.
75-178. The period of his entry to his father's office is described on pp. 87-92.

59. Gates, Autobiography, pp. 517-18; Nevins, Rockefeller, II, 289.

60. Raymond Fosdick, John D. Rockefeller, Jr., A Portrait (New York: Harper and
Bros., 1956), p. Ill; Nevins, Rockefeller, II, 290.

61 . Raymond Fosdick, The Story of the Rockefeller Foundation (New York: Harper
and Bros., 1952), p. 2.

62. For the authorized and largely uncritical histories of the Rockefeller philanthro-
pies, see Fosdick's history of the Rockefeller Foundation, cited above, and his
Adventure in Giving: The Story of the General Education Board (New York:
Harper and Row, 1962); George W. Comer, A History of the Rockefeller

Notes to Pages 43-47 I 247

Institute— 1901-1953 (New York: Rockefeller Institute Press, 1964); and Greer
Williams, The Plague Killers (New York: Charles Scribner's Sons, 1969), about
the worldwide public health programs. For more critical views, see Harry
Cleaver, Jr., "The Origins of the Green Revolution," unpublished doctoral
dissertation, Stanford University, 1975; E. Richard Brown, "Public Health in
Imperialism: Early Rockefeller Programs at Home and Abroad," American
Journal of Public Health, 66 (1976), 897-903; Collier and Horowitz, Rockefel-
lers; and the following chapters in this book.

63. Quoted in Nevins, Rockefeller, II, 291.

64. Rockefeller, Random Reminiscences, pp. 159-60.

65. See F. Emerson Andrews, Philanthropic Giving (New York: Russell Sage
Foundation, 1950); Warren Weaver, U.S. Philanthropic Foundations— Their
History, Structure, Management, and Record (New York: Harper and Row,
1967); and Bremner, American Philanthropy.

66. See Franklin Parker, George Peabody, A Biography (Nashville: Vanderbilt
University Press, 1971), pp. 160-67, on the founding of the Peabody Fund; and
see Jessie Pearl Rice, J. L. M. Curry — Southerner, Statesman, and Educator
(New York: Columbia University Press, 1949), pp. 159-75, on Curry's role in
Southern education funds.

67. Lx)uis R. Harlan, Separate and Unequal: Public School Campaigns and Racism
in the Southern Seaboard States, 1901-1915 (Chapel Hill: University of North
Carolina Press, 1958), discusses the Southern Education Board, pp. 75-101.
Some of the important contributions to the board's total income, $400,000 in the
thirteen years of its existence, came from George Foster Peabody, Andrew
Carnegie, Rockefeller's General Education Board, Frank R. Chambers of New
York, the Russell Sage Foundation, and Robert C. Ogden.

68. Hugh C. Bailey, Liberalism in the New South — Southern Social Reformers and
the Progressive Movement (Coral Gables, Fla.: University of Miami Press,
1969), p. 138.

69. Harlan, Separate and Unequal, pp. 75-101; Bailey, Liberalism, pp. 75-76;
Lawrence A. Cremin, The Transformation of the School — Progressivism in
American Education, 1876-1957 (New York: Knopf, 1961), pp. 23-57. Wash-
ington was financially supported by Northern businessmen and Southern
liberals; he was hired as an agent of the SEB though he was never allowed to
attend a board meeting. More assertive black leaders denounced the Hampton
model of industrial schooling for blacks. W. E. B. DuBois pointed out that
exclusive support of industrial schooling emphasized blacks' duties and put their
rights into the background. "Take the eyes of these millions off the stars and
fasten them in the soil," he mockingly told a Hampton audience, and let their
dreams be of "com bread and molasses." DuBois, The Education of Black
People, ed. H. Aptheker (Amherst: University of Massachusetts Press, 1973),
p. 9.

70. Quoted in Cleaver, "Origins of the Green Revolution."

71. Fosdick, Adventure in Giving, pp. 10-11. SEB member William H. Baldwin,
president of the Long Island Railroad, argued that blacks "will willingly fill the
more menial positions, and do the heavy work, at less wages," leaving to whites
"the more expert labor," Harlan, Separate and Unequal, p. 78, 75-101.

72. Fosdick, Rockefeller, Jr., pp. 117-18.

73. Memorandum in Rockefeller Family Archives, record group 2.

74. Copy of press release in Rockefeller Family Archives, record group 2.

75. Harlan, Separate and Unequal, pp. 75-101; Frissell quoted on p. 86.

76. Fosdick, Adventure in Giving, pp. 10-11; Buttrick to Gates, Oct. 14, 1904;
confidential report of Jerome D. Greene, Wallace Buttrick, and Abraham

248 I Notes to Pages 47-56

Flexner, Oct. 22, 1914; Raymond B. Fosdick, Wickliffe Rose, and James
Diliard, report of special committee on programs and policies, Oct. 6, 1922, all
in GEB files. Rockefeller Foundation Archives. The GEE greatly influenced
several other foundations that worked in the Southern education movement;
e.g., see Abraham Flexner, Abraham Flexner: An Autobiography (New York:
Simon and Schuster, 1960), p. 274; this is a revision of his autobiography
published in 1940 as / Remember.
11. Gates, Autobiography, pp. 460-64; Gates to Wickliffe Rose, Aug. 21, 1914,
Rockefeller Sanitary Commission files; R. B. Fosdick, W. Rose, and J. Diliard,
report of special committee on programs and pwlicies, Oct. 6, 1922, GEB files;
Annual Report of the General Education Board, 1921-1922, pp. 42, 65.

78. See Brown, "Public Health in Imperialism."

79. Gates, Autobiography, p. 460.

80. Gates to Rockefeller, June 3, 1905, Gates papers. Rockefeller Foundation
Archives.

81. Gates, Autobiography, pp. 440-42.

82. Current Literature, 42 (1909), 253-54; Gates to Rockefeller, Aug. 9, 1907,
Gates papers.

83. Gates, "Some Reflections on Questions of Policy," memo to the board, Jan. 23,
1906. GEB files. Rockefeller Foundation Archives.

84. William S. Vickery, "One Economist's View of Philanthropy," in F. G.
Dickerson, ed.. Philanthropy and Public Policy (New York: National Bureau of
Economic Research, 1962), p. 31.

85. Wall, Carnegie, p. 828.

86. The origins and early years of the Carnegie Foundation are described in Burton
J. Hendrick, The Life of Andrew Carnegie (Garden City, N.Y.: Doubleday,
Doran, and Co., 1932), vol. 2, 263-64; and Wall, Carnegie, pp. 869-79.

87. Henry S. Pritchett, "Introduction" to Abraham Flexner, Medical Education in
the United States and Canada, Bulletin no. 4 (New York: Carnegie Foundation
for the Advancement of Teaching, 1910), p. vii. See also A. Flexner, Henry S.
Pritchett, A Biography (New York: Columbia University Press, 1943), p. 96.

88. Phone conversation quoted in Buttrick to Gates, March 30, 1906; see also
Buttrick to Pritchett, March 31, 1906, and April 16, 1906; and Pritchett to
Buttrick, April 5, 1906. and Jan. 4, 1909, all in GEB files. Rockefeller
Foundation Archives. See also Pritchett to Buttrick, Feb. 3, 1911, Feb. 6, 1911,
Nov. 12, 1915, and Nov. 24, 1916; and Buttrick to Pritchett, Feb. 8, 1911, and
Dec. 1, 1916; and Pritchett to Gates, Nov. 12, 1915, all in Carnegie Foundation
files.

89. Gates to Rockefeller, June 6, 1905, Rockefeller Family Archives, record group
2.

90. W. Buttrick to H. S. Pritchett, May 29, 1917, Carnegie Foundation files; A.
Flexner, "Supplement to the Gedney-Farm Memorandum," March 31, 1924,
GEB files, Rockefeller Foundation Archives. A. Flexner, Autobiography, pp.
127, 129.

91. Fosdick, Rockefeller, Jr., pp. 143-87; and Collier and Horowitz, Rockefellers,
pp. 109-34.

92. Charles P. Howland to Raymond B. Fosdick, Jan. 28, 1927, Rockefeller
Foundation files; A. Flexner to W. Buttrick, Aug. 3, 1925, GEB files; A. P.
Stokes to W. Rose. May 2, 1928, and Edwin R. Embree to George Vincent,
May 7, 1928, GEB files; memos by Edwin Embree about 1932, Edwin Embree
papers — all Rockefeller Foundation Archives.

93. Gates, memo to himself, Nov. 20, 1911, Rockefeller Family Archives, record
group 2.

Notes to Pages 56-64 I 249

94. Rockefeller, Jr., to Rockefeller, Dec. 31, 1906, Rockefeller Family Archives,
record group 2.

95. Gates, memo to GEB, Nov. 1911, Rockefeller Family Archives, record group 2.

96. University of Chicago relationship described and letter quoted in Nevins,
Rockefeller, II, 230-31, 246, 265-M, 627.

97. Gates to George Foster Peabody, March 20, 1912, Rockefeller Family Ar-
chives, record group 2; Annual Report of the General Education Board, 1924-
1925, p. 5; A. Flexner, Autobiography, p. 209.

98. Williams, Contours, pp. 352-53. An illustration of the profitable use of
managers comes from Carnegie's career. In 1873 Carnegie hired Captain
WiUiam Jones to run his steel mill, and it was largely Jones who kept the
company's costs below and its profits above those of its competitors. Jones
introduced technical innovations that he personally designed, and he maintained
relatively stable relations with his workers despite the intolerably exploitative
wages and working conditions he and the company imposed on them. He
worked the men under him twelve hours a day, seven days a week in mills where
temperatures frequently topped 100°, but he also understood the necessity of
setting some floor below which wages would not be pushed in order to keep his
workers — a position that Carnegie had difficulty accepting. On Jones' role, see
Wall, Carnegie, pp. 314-16, 328-29, 344^5.

99. A. Flexner, Autobiography, p. 109.

CHAPTER 2

1. Joseph E. Kett, The Formation of the American Medical Profession— The Role
of Institutions, 1780-1860 (New Haven: Yale University Press, 1968), pp. 9-10.

2. William G. Rothstein, American Physicians in the Nineteenth Century (Balti-
more: Johns Hopkins University Press, 1972), pp. 35-36.

3. A Maryland physician named Alexander Hamilton complained of the empirics
he found in his travels through the colonies in 1744. "A great many of them take
the care of a family for the value of a Dutch dollar a year, which makes the
practice of physick a mean thing, and unworthy of the application of a
gentleman." Quoted in Rothstein, American Physicians, p. 35.

4. L. H. Butterfield, ed., Letters of Benjamin Rush (Princeton: Princeton
University Press, 1951), vol. 2, 661.

5. On lay healers, see Barbara Ehrenreich and Deirdre English, Witches, Mid-
wives, and Nurses: A History of Women Healers (Old Westbury, N.Y.: The
Feminist Press, 1973); and Kett, Formation.

6. For a detailed description and discussion of regular medical practice in the first
half of the nineteenth century, see Rothstein, American Physicians, pp. 41-62.

7. On the Popular Health Movement and some of its component groups, see
Richard H. Shryock, "Sylvester Graham and the Popular Health Movement,
1830-1870," in Shryock, Medicine in America, Historical Essays (Baltimore:
Johns Hopkins Press, 1966), pp. 111-25; and Ehrenreich and English, Witches,
pp. 22-25. On licensing, see Shryock, Medical Licensing in America, 1650-1965
(Baltimore: Johns Hopkins Press, 1967).

8. See Rothstein, American Physicians, pp. 152-74; and Harris L. Coulter,
Divided Legacy, 3 vols. (Washington, D.C.: McGrath Publishing Co., 1973).

9. Rosemary Stevens, American Medicine and the Public Interest (New Haven:
Yale University Press, 1971), p. 24.

10. Rothstein, American Physicians, p. 95.

11. "Medical Education in the United States," JAMA, 79 (1922), 629-37.

12. Kett, Formation, p. 179.

250 I Notes to Pages 65-76

13. Dr. S. E. Chains, quoted in Gerald E. Markowitz and David K. Rosner,
"Doctors in Crisis: A Study of the Use of Medical Education Reform to
Establish Modern Professional Elitism in Medicine," American Quarterly, 25
(1973), 90.

14. KoXhslt'm, American Physicians, pp. 120-21.

15. The Three Ethical Codes (Detroit: Illustrated Medical Journal Co., 1888), p. 31.
This publication includes codes of ethics of the AMA, the American Institute of
Homeopathy, and the National Eclectic Medical Society.

16. Donald E. Konold, A History of American Medical Ethics, 1847-1912 (Madi-
son: State Historical Society of Wisconsin for the Department of History,
University of Wisconsin, 1962), pp. 1-24. Regarding the internal and external
functions of codes of ethics in the medical profession, see Jeffrey L. Berlant,
Profession and Monopoly (Berkeley: University of California Press, 1975),
chap. 3.

17. Abraham Flexner, Medical Education in the United States and Canada, Bulletin
no. 4 (New York: Carnegie Foundation for the Advancement of Teaching,
1910), p. 14.

18. A. M. Carr-Saunders, "Professionalization in Historical Perspective," in H. M.
VoUmer and D. L. Mills, eds., Professionalization (Englewood Cliffs, N.J.:
Prentice-Hall, 1966), pp. 3-4.

19. William J. Goode, "Encroachment, Charlatanism, and the Emerging Profes-
sions: Psychology, Medicine, and Sociology," American Sociological Review, 25
(1960), 902-14.

20. Ernest Greenwood, "Attributes of a Profession," Social Work, 2 (1957), 44-55.

21. Eliot Freidson, Profession of Medicine: A Study of the Sociology of Applied
Knowledge (New York: Dodd, Mead and Co., 1970), p. 80.

22. Harold L. Wilensky, "The Professionalization of Everyone?" American Journal
of Sociology, 70 (1964), 137-58.

23. Freidson, Profession, p. 81.

24. Carr-Saunders, "Professionalization," p. 6.

25. Everett C. Hughes, "Professions," in Kenneth S. Lynn, ed.. The Professions in
America (Boston: Houghton Mifflin Co., for American Academy of Arts and
Sciences, 1965), pp. 2, 3, 9.

26. Freidson, Profession, pp. 79, 80 (emphasis added).

27. Henry E. Sigerist, American Medicine (New York: W. W. Norton and Co.,
1934), pp. 267-73.

28. George W. Corner, A History of the Rockefeller Institute— 1901-1953 (New
York: Rockefeller Institute Press, 1964), pp. 7-8.

29. Stevens, American Medicine, p. 40.

30. Sigerist, American Medicine, pp. 273-74.

31. See, for example, William Allen Pusey, A Doctor of the 1870s and 1880s
(Springfield, III.: Charles C. Thomas, 1932).

32. Rothstein, American Physicians, p. 209.

33. For an illuminating analysis of scientific management, see Harry Braverman,
Labor and Monopoly Capital — The Degradation of Work in the Twentieth
Century (New York: Monthly Review Press, 1974), pp. 70-138.

34. John Powles, "On the Limitations of Modern Medicine," Science, Medicine,
and Man, 1 (1973), 15.

35. Markowitz and Rosner, "Doctors," 92.

36. Erwin H. Ackerknecht, A Short History of Medicine (New York: Ronald Press,
1955), pp. 130-31.

37. Charles E. Rosenberg, The Cholera Years— The United States in 1832, 1849, and
1866 (Chicago: University of Chicago Press, 1962).

Notes to Pages 76-86 I 251

38. Corner, Rockefeller Institute, p. 4. See also Edward H. Kass, "Infectious
Diseases and Social Change," Journal of Infectious Diseases, 123 (1971),
110-14.

39. Richard H. Shryock, American Medical Research, Past and Present (New York:
Commonwealth Fund, 1947), pp. 43-44. See also Corner, Rockefeller Institute,
pp. 8-9, on rising public interest in and expectations from medical science.

40. Leonard Keene Hirshberg, "Popular Medical Fallacies," American Magazine,
62 (1906), 655-60; Harvey Cushing, "Triumphs of Modern Medicine," Educa-
tion Review, 47 (1914), 86-95; and C.-E. A. Winslow, "The War Against
Disease," Atlantic Monthly, 91 (Jan. 1903), 43-52. The New York Times (Feb.
19, 1911) reported on a lecture by Dr. Harvey Wiley, then chief chemist with the
U.S. Department of Agriculture and later first head of the Food and Drug
Administration, in which he asserted that in fifty years chemistry will have
practically eliminated all forms of disease.

41. See, for example, Charles A. L. Reed, "President's Address," JAMA, 36
(1901), 1599-1606.

42. William H. Welch, "Medical Advancement," American Magazine, 6 (1903),
675; quoted in Markowitz and Rosner, "Doctors," 92.

43. Elizabeth Bisland, "The Tyranny of the Pill," North American Review, 190
(1909), 819-25.

44. Pusey, Doctor.

45. Fielding H. Garrison, John Shaw Billings, A Memoir (New York: G. P.
Putnam's Sons, 1915), pp. 256-57.

46. Richard H. Shryock, The Unique Influence of the Johns Hopkins University on
American Medicine (Copenhagen: Ejnar Munksgaard, Ltd., 1953), p. 19.

47. Donald Fleming, William H. Welch and the Rise of Modern Medicine (Boston:
Little, Brown and Co., 1954), especially p. 21. Welch's letter to his sister is
quoted in Simon Flexner and James Thomas Flexner, William Henry Welch and
the Heroic Age of American Medicine (New York: Viking Press, 1941), pp.
75-76.

48. Konold, Ethics, pp. 33-35.

49. Ibid., p. 58.

50. Rothstein, American Physicians, pp. 292-94.

51. C. A. L. Reed, "President's Address," JAMA, 36 (1901), 1605.

52. A. Flexner, Medical Education, pp. 10-11. See also Rothstein, American
Physicians, p. 19.

53. "Medical Education in the United States," JAMA, 79 (1922), 629-37.

54. W. J. Reader, Professional Men — The Rise of the Professional Classes in
Nineteenth-Century England (New York: Basic Books, 1966), pp. 10-17.

55. Richard Hofstadter, "The Age of the College," in R. Hofstadter and W. P.
Metzger, The Development of Academic Freedom in the United States (New
York: Columbia University Press, 1955), p. 228.

56. Daniel Drake, Practical Essays on Medical Education and the Medical Profes-
sion in the United States (Cincinnati: Roff and Young, 1832; reprinted by Johns
Hopkins Press, 1952), p. 11.

57. William H. Welch, from an article in Science, quoted in Markowitz and Rosner,
"Doctors," 95.

58. Inez C. Philbrick, "Medical Colleges and Professional Standards," JAMA, 36
(1901), 1700.

59. Frank Billings, "Medical Education in the United States," President's Address,
JAMA, 40 (1903), 1271-76.

60. Quoted in James J. Walsh, History of the Medical Society of the State of New
York (New York: The Medical Society, 1907), p. 173.

252 I Notes to Pages 86-94

61. Bryan, it should be noted, argued not from the needs of the working class nor
even humanitarian grounds. An early advocate of what has become known as
the "equal opportunity" doctrine, his argument for including the poorer classes
in medicine came from his belief that "it is certain the only hope of this country
for salvation from anarchy is in keeping the doors of higher opportunity open to
the poorest." From Association of American Medical Colleges, Proceedings of
the 18th Annual Meeting, Cleveland, March 16-17, 1908, p. 37.

62. F. C. Shattuck and J. L. Bremer, "The Medical School, 1869-1929," in S. E.
Morison, ed., The Development of Harvard University, 1869-1929 (Cambridge,
Mass.: Harvard University Press, 1930), p. 581.

63. Quoted in Garrison, Billings, p. 256.

64. Philbrick, "Medical Colleges," 1700-02.

65. Rothstein, American Physicians, pp. 230-34.

66. Kett, Formation, pp. 135-38.

67. Walter L. Burrage, A History of the Massachusetts Medical Society, 1781-1922.
(Norwood, Mass.: Plimpton Press, 1923), pp. 426-27; and Konold, Ethics, pp.
22-26.

68. Quoted in Rothstein, American Physicians, p. 245 (emphasis added).

69. Ibid., p. 307. See also. Richard Shryock, Medical Licensing in America,
1650-1965 (Baltimore: Johns Hopkins Press, 1967), pp. 51-52.

70. Shryock, Medical Licensing, pp. 53-54; Robert C. Derbyshire, Medical
Licensure and Discipline in the United States (Baltimore: Johns Hopkins Press,
1969), p. 7; Stevens, American Medicine, p. 43; and Berlant, Profession and
Monopoly, chap. 5.

71. Rothstein, American Physicians, pp. 307-09.

72. Reed, "President's Address," 1605.

73. "Report of the Committee on Medical Ethics," JAMA, 40 (1903), 1379-81.

74. Reed, "President's Address," 1605.

75. Rothstein, American Physicians, p. 23.

76. See, for example, T. McKeown, "A Conceptual Background for Research and
Development in Medicine," International Journal of Health Services, 3 (1973),
17-28; and Powles, "Limitations."

77. Stevens, American Medicine, p. 40.

78. Edgar Allen Forbes, "Is the Doctor a Shylock?" World's Work, 14 (1907),
8892-96.

79. B. Ehrenreich and D. English, Complaints and Disorders: The Sexual Politics of
Sickness (Old Westbury, N.Y.: The Feminist Press, 1973). See also their For
Her Own Good: 150 Years of the Experts' Advice to Women (Garden City,
N.Y.: Anchor Press/Doubleday, 1978).

80. H. Bigelow, "The Conservation of Energy and Conservative Gynaecology,"
JAMA, 4 {\8S5),3U.

81. Quoted in Stevens, American Medicine, p. 50.

82. Konold, Ethics, pp. 35-37; and "Report of the Committee on Specialties, and
on the Propriety of Specialists Advertising," Transactions of the AMA, 20
(1869), 111-13.

83. Konold, Ethics, pp. 38-40.

84. Stevens, American Medicine, p. 50.

85. Figures based on Rothstein's estimate {American Physicians, p. 344) of the
number of physicians in the United States in 1900 less 5 percent who may have
been full-time specialists, while the current figure is from Cambridge Research
Institute, Trends Affecting the U.S. Health Care System (Washington, D.C.:
Government Printing Office, 1976), pp. 357-66.

Notes to Pages 94-109 I 253

86. Stevens, American Medicine, pp. 85-88, 92.

87. Maurice D. Clarke, "Therapeutic Nihilism," quoted in Rothstein, American
Physicians, pp. 184-85.

88. Rothstein, American Physicians, p. 324.

89. Stevens, American Medicine, p. 134.

90. On the successful campaign to get rid of midwives, see Frances E. Kobrin, "The
American Midwife Controversy: A Crisis of Professionalization," Bulletin of the
History of Medicine, 40 (1966), 350-63.

91. Morris Fishbein, The New Medical Follies (New York: Boni and Liveright,
1927), p. 231.

CHAPTER 3

1. Sander Kelman describes the contradiction that technological medicine posed
for private practice physicians in their attempt to control the profession in
"Toward the Political Economy of Medical Care," Inquiry, 8 (Sept. 1971),
30-37.

2. Rosemary Stevens, American Medicine and the Public Interest (New Haven:
Yale University Press, 1971), pp. 78, 52. On the cost of hospital construction,
see C. Rufus Rorem, The Public's Investment in Hospitals (Chicago: University
of Chicago Press, 1930), especially pp. 124-25.

3. Stevens, American Medicine, p. 145.

4. Richard Hofstadter, The Age of Reform (New York: Vintage Books, 1955), pp.
137-38.

5. JAMA, 35 (1900), 1353.

6. Simon Flexner and James Thomas Flexner, William Henry Welch and the
Heroic Age of American Medicine (New York: Viking Press, 1941), pp. 111-17.

7. Ibid., pp. 130-34.

8. Donald Fleming, William H. Welch and the Rise of Modern Medicine (Boston:
Little, Brown and Co., 1954), conveys the impression that Welch was driven by
competition. See also S. Flexner and J. T. Flexner, Welch, p. 138.

9. Fleming, Welch, pp. 65-70; and Flexner and Flexner, Welch, pp. 136, 154, 171.

10. The account is printed in full as "Recollections of Frederick T. Gates on the
Origins of the Institute," in George W. Comer's official A History of the
Rockefeller Institute— 1901-1953 (New York: Rockefeller Institute Press, 1964),
pp. 575-84. It is extensively relied on by Comer and by Allan Nevins, John D.
Rockefeller, The Heroic Age of American Enterprise (New York: Charles
Scribner's Sons, 1940), vol. 2, 466-70; and Hexner and Flexner, Welch, 269-71.
I have also quoted and referred to Gates' memo in the following pages.

11. Comer, Rockefeller Institute, p. 30; and a letter from L. Emmett Holt, quoted in
T. Mitchell Prudden's unpublished history of the Rockefeller Institute.

12. Comer, Rockefeller Institute, pp. 30-31.

13. Ibid., pp. 51-52.

14. Frederick T. Gates, Autobiography, unpublished ms., 1928, pp. 387-88, Gates
collection, Rockefeller Foundation Archives; and Comer, Rockefeller Institute,
p. 49.

15. Comer, Rockefeller Institute, p. 68.

16. Ibid., pp. 39-40.

17. Ibid., pp. 40-41.

18. John D. Rockefeller to Starr J. Murphy, Dec. 29, 1916, Rockefeller Family
Archives, record group 2.

254 I Notes to Pages 110-117

19. John D. Rockefeller to Starr J. Murphy, July 1, 1919, Rockefeller Family
Archives, record group 2.

20. Starr J. Murphy to John D. Rockefeller, July 8, 1919, Rockefeller Family
Archives, record group 2.

21. Frederick T. Gates to John D. Rockefeller, Jan. 20, 1911, Gates collection,
Rockefeller Foundation Archives.

22. John D. Rockefeller, Jr., to Starr J. Murphy, July 5, 1919, Rockefeller Family
Archives, record group 2.

23. Starr J. Murphy to John D. Rockefeller, Jan. 2, 1917, Rockefeller Family
Archives, record group 2.

24. William G. Rothstein, American Physicians in the Nineteenth Century (Balti-
more: Johns Hopkins University Press, 1972), pp. 159-60, 234-39.

25. Quoted in Raymond B. Fosdick, John D. Rockefeller, Jr., A Portrait (New
York: Harper and Bros., 1956), pp. 111-12.

26. The McGill appeal is related in Corner, Rockefeller Institute, pp. 70-71.

27. Gates, "Philanthropy and Civilization," 1923, Gates collection, Rockefeller
Foundation Archives.

28. Gates, "Some Elements of an Effective System of Scientific Medicine in the
United States" (n.d.), Gates collection. Rockefeller Foundation Archives.

29. Gates, "Concerning Private Gifts to States and a Medical Policy," Memo to the
General Education Board, Feb. 26, 1925, Gates collection, Rockefeller
Foundation Archives.

30. Gates, "Philanthropy and Civilization."

31. Gates, "Private Gifts."

32. Walter Fisher, "Physicians and Slavery in the Ante-bellum Southern Medical
Journal," Journal of the History of Medicine and Allied Sciences, 23 (1968),
36-49.

33. Ibid., 37.

34. Quoted in George M. Frederickson, The Inner Civil War: Northern Intellectuals
and the Crisis of the Union (New York: Harper and Row, 1965), pp. 102-04. My
thanks to Michael Cohen for calling my attention to this chapter.

35. Carnegie quotes himself in Autobiography of Andrew Carnegie (Boston:
Houghton Mifflin Co., 1920), p. 231.

36. Quoted in David Brody's excellent study of working conditions, labor organiz-
ing, and employers, Steelworkers in America: The Nonunion Era (New York:
Harper and Row, 1969; originally published, 1960), p. 178. See also Stuart D.
Brandes, American Welfare Capitalism, 1880-1940 (Chicago: University of
Chicago Press, 1976).

37. Frederick T. Gates to John D. Rockefeller, Dec. 12, 1910, Rockefeller Family
Archives, record group 2. See also E. Richard Brown, "Public Heahh in
Imperialism: Early Rockefeller Programs at Home and Abroad," American
Journal of Public Health, 66 (1976), 897-903; Greer Williams, The Plague
Killers (New York: Charles Scribner's Sons, 1969); Mary Boccaccio, "Ground
Itch and Dew Poison: The Rockefeller Sanitary Commission, 1909-1914,"
Journal of the History of Medicine and Allied Sciences, 11 (1972), 30-53; and
James H. Cassedy, "The 'Germ of Laziness' in the South, 1900-1915: Charles
Warden Stiles and th6 Progressive Paradox," Bulletin of the History of
Medicine, 45 (1971), 159-69.

38. May quoted in Tropical Health — A Report on a Study of Needs and Resources
(Washington, D.C.: National Academy of Sciences, National Research Council,
Publication no. 996, 1962). pp. vii-viii. See also Brown, "Public Health in
Imperialism," and Williams, Plague Killers.

Notes to Pages 117-126 I 255

39. Quoted in "Recent American Opinion in Favor of Health Insurance,"
American Labor Legislation Review, 6 (1916), 347.

40. Quoted in ibid., 345.

41. On the history of European sickness insurance programs, see Matthew J. Lynch
and Stanley S. Raphael, Medicine and the State (Springfield, 111.: Charles C.
Thomas, 1963). On the social reforms of Progressivism, see James Weinstein,
The Corporate Ideal in the Liberal State, 1900-1918 (Boston: Beacon Press,
1968).

42. C. W. Hopkins, "The Hospital Organization of Railway Systems," in Medicine,
An Aid to Commerce, paper from 40th Annual Meeting of the American
Academy of Medicine, San Francisco, June 25-28, 1915 (Easton, Pa.: American
Academy of Medicine, 1916), pp. 149-52.

43. Charles W. Eliot, "The Qualities of the Scientific Investigator," in Addresses
Delivered at the Opening of the Laboratories in New York City, May 11, 1906
(New York: Rockefeller Institute for Medical Research, 1906), p. 49.

44. W. H. Welch, "The Benefits of the Endowment of Medical Research," in
Addresses (Rockefeller Institute), p. 32.

45. Gates, "Notes on Homeopathy, No. 3," written as a memo to Rockefeller, Sr.,
and circulated approvingly within the Rockefeller philanthropies about 1911,
Gates collection, Rockefeller Foundation Archives. Gates' quotes on the next
few pages are taken from this memo.

46. Gates, "Address on the Tenth Anniversary of the Rockefeller Institute," 1911,
Gates collection. Rockefeller Foundation Archives.

47. F. T. Gates to J. D. Rockefeller, Jan. 31, 1905, Letterbook no. 350, Rockefeller
Family Archives, record group 1.

48. J. A. Hobson, Imperialism (London: George Allen & Unwin, 1938; originally
published 1902).

49. Described and quoted in a newsletter published for a short time by the
foundation, "Hospital Ship for the Sulu Archipelago," The Rockefeller Founda-
tion, Aug. 15, 1916, pp. 1, 14.

50. George E. Vincent, The Rockefeller Foundation — A Review of Its War Work,
Public Health Activities, and Medical Education Projects in 1917 (New York:
Rockefeller Foundation, 1918), pp. 31-32.

51. For a history of class conflicts over the reform of public schools, see Joel H.
Spring, Education and the Rise of the Corporate State (Boston: Beacon Press,
1972); and Michael B. Katz, Class, Bureaucracy, and Schools — The Illusion of
Educational Change in America (New York: Praeger Publishers, 1971).

52. New London (Conn.) Day, July 10, 1914.

53. Autobiography, p. 281.

54. Gates, "Address." Gates had grown very ecumenical indeed: "Rev. Simon
Flexner, D.D." was Jewish.

55. Speech reprinted in John B. Roberts, The Doctor's Duty to the State: Essays on
the Public Relations of Physicians (Chicago: American Medical Association,
1908), especially p. 20. Roberts was also a member of the AMA Committee on
Legislation, one of the profession's powerful lobbying units.

56. Jiirgen Habermas, "Technology and Science as 'Ideology,' " in Habermas,
Toward a Rational Society — Student Protest, Science, and Politics (Boston:
Beacon Press, 1971), p. 105. See also Herbert Marcuse, One-Dimensional Man
(Boston: Beacon Press, 1964).

57. See Samuel Haber, Efficiency and Uplift: Scientific Management in the
Progressive Era, 1890-1920 (Chicago: University of Chicago, 1964); and Harry
Braverman's excellent study. Labor and Monopoly Capital — The Degradation of

256 I Notes to Pages 126-137

Work in the Twentieth Century (New York and London: Monthly Review Press,
1974).

58. Quoted in Haber, Efficiency and Uplift, p. 20.

59. A writer of the period quoted in ibid., p. 62.

60. Nicholas Murray Butler, "Scientific Research and Material Progress," in
Addresses (Rockefeller Institute), p. 40.

61. Ibid., p. 39.

62. Quoted in George Rosen, "The Evolution of Social Medicine," in H. E.
Freeman, S. Levine, and L. G. Reeder, eds. Handbook of Medical Sociology,
2nd ed. (Englewood Cliffs, N.J.: Prentice-Hall, 1972), p. 39.

63. Ren6 J. Dubos, "The Gold-Headed Cane in the Laboratory," in Annual
Lectures, 1953 (Washington, D.C.: National Institutes of Health, 1953), pp.
89-102.

64. Gates to Rockefeller, Sr., Oct. 8, 1910, Rockefeller Family Archives, record
group 2.

65. Gates, "Philanthropy and Civilization."

66. Gates, Autobiography, p. 395.

67. See, for example. Studies from the Rockefeller Institute for Medical Research,
Index for Volumes I-XV (New York: Rockefeller Institute, 1912).

68. See Corner's Rockefeller Institute, which describes the lines of research pursued
at the institute from 1901 to 1953.

69. Shryock notes the "heavy emphasis and reliance on the basic sciences" at the
new Johns Hopkins School of Hygiene and Public Health in his The Unique
Influence of the Johns Hopkins University on American Medicine (Copenhagen:
Ejnar Munksgaard, Ltd., 1953), pp. 49-50.

70. C. W. Stiles, "Soil Pollution: The Chain Gang as a Possible Disseminator of
Intestinal Parasites and Infections," Public Health Reports, 28 (1913), 985-86.

71. Gates, "Capital and Labor," memorandum (n.d., but probably 1916), Gates
collection. Rockefeller Foundation Archives. Quotes on pages 130-131 are from
this memo.

72. Quotes in this paragraph taken from two similar passages in Gates' "Address,"
and Autobiography, pp. 396-97.

73. "Address."

74. Ibid.

75. "Philanthropy and Civilization."

76. Quotes in this paragraph are taken from similar passages in Gates, "Address,"
and Gates, Autobiography, pp. 399-400.

CHAPTER 4

1. Quoted in Gerald E. Markowitz and David K. Rosner, "Doctors in Crisis: A
Study of the Use of Medical Education Reform to Establish Modern Profession-
al Elitism in Medicine," American Quarterly, 25 (1973), 88.

2. JAMA, 37 (1901), 270.

3. Richard H. Shryock, Medical Licensing in America, 1650-1965 (Baltimore:
Johns Hopkins Press, 1967), pp. 53-54.

4. Rosemary Stevens, American Medicine and the Public Interest (New Haven:
Yale University Press, 1971), p. 24.

5. Markowitz and Rosner, "Doctors," 87.

6. Morris Fishbein, A History of the American Medical Association, 1847 to 1947
(Phila.: W. B. Saunders Co., 1947), pp. 206-13; William G. Rothstein,

Notes to Pages 138-145 I 257

American Physicians in the Nineteenth Century (Baltimore: Johns Hopkins
University Press, 1972), pp. 69-70, 317-18; Stevens, American Medicine, p. 29;
and James G. Burrow, AM A, Voice of American Medicine (Baltimore: Johns
Hopkins Press, 1963), pp. 27-32.

7. Quoted in Fishbein, History, p. 211.

8. One physician, unhappy with the new leadership, criticized the AMA for being
self-proclaimed politicians of the profession, for representing only about 8
percent of the country's doctors, and for being controlled by merely "a half
dozen men." See B. M. Jackson, "The Medical Profession: Its Politics and
Politicians," Pacific Medical Journal, Al (1904), 456-61.

9. On the coalition of university medical school physicians and private practition-
ers, their interests, strategy, and effect, see the excellent article by Markowitz
and Rosner, "Doctors."

10. Arthur D. Bevan, "Cooperation in Medical Education and Medical Service,"
JAMA, 90 (1928), 1173.

11. "Council on Medical Education of the AMA," JAMA, 48 (1907), 1702.

12. Sxtvtns^ American Medicine, pp. 65-66. Today, in half the fifty states the state
medical society has a direct hand in selecting the licensing board, according to
Robert C. Derbyshire, Medical Licensure and Discipline in the United States
(Baltimore: Johns Hopkins Press, 1969), p. 33.

13. "Council," JAMA, 48 (1907), 1702-05.

14. Bevan, "Cooperation," 1174-75; and "Medical Education in the United
States," JAMA, 79 (1922), 629-37.

15. See, for example, George M. Kober's presidential address in Association of
American Medical Colleges, Proceedings of the 17th Annual Meeting, Washing-
ton, D.C., May 6, 1907, pp. 31-32.

16. "Council," 1703.

17. JAMA, 35 (1900), 1353.

18. "Council," 1703.

19. JAMA, 37 (1901), 200-01.

20. "Council," 1703.

21. "Council on Medical Education of the AMA," JAMA, 44 (1905), 1471.

22. Abraham Flexner, Henry S. Pritchett: A Biography (New York: Columbia
University Press, 1943), p. 108.

23. Howard J. Savage, Fruit of an Impulse, 45 Years of the Carnegie Foundation,
1905-1950 (New York: Harcourt, Brace and Co., 1953), pp. 30, 54-55, 73-78;
and A. Flexner, Pritchett, p. 97.

24. Information on precisely how Abraham Flexner's name was suggested to
Pritchett is not readily available. But this scenario seems most consistent with
available accounts and information. See Savage, Fruit, p. 105.

25. Abraham Flexner, Abraham Flexner: An Autobiography (New York: Simon
and Schuster, 1960), pp. 45, 70-71.

26. Regarding Pritchett's views on the relationship of the medical study to the
foundation's general program, see Pritchett's "Introduction," in Abraham
Flexner, Medical Education in the United States and Canada, Bulletin no. 4
(New York: Carnegie Foundation for the Advancement of Teaching, 1910), p.
xi.

27. Ibid., p. viii.

28. A. Flexner, Autobiography, p. 74.

29. Ibid., p. 85.

30. Ibid., p. 74; Stevens, American Medicine, pp. 66-67. Five medical schools had
closed between the Council on Medical Education's survey in 1906 and Flexner's
survey in 1909.

258 I Motes to Pages 146-152

31. A. Flexner, Pritchett, p. 110.

32. Pritchett, "Introduction," in A. Flexner, Medical Education, p. ix.

33. Henry S. Pritchett to Jerome D. Greene, Pritchett to Cyrus Adler, and Pritchett
to Dr. William T. Councilman, Jan. 22, 1909; Councilman to Pritchett, Jan. 26,
1909. Pritchett papers. Library of Congress.

34. A. Flexner, Medical Education, pp. 24—26.

35. Pritchett, "Introduction," in ibid., p. xiv,

36. Flexner, Medical Education, pp. 14-18 (emphasis added).

37. Ibid., pp. 7-8.

38. Ibid., p. 19.

39. Ibid., pp. 18-19, 48; Pritchett, "Introduction," in ibid., p. x.

40. National Center for Education Statistics. Digest of Educational Statistics, 1974
(Washington, D.C.: Government Printing Office, 1975), pp. 33, 76.

41. A. Flexner, Medical Education, pp. 180-81.

42. Ibid., pp. 178-80; and Flexner, Autobiography, p. 207. See also Barbara
Ehrenreich and Deirdre English. Complaints and Disorders: The Sexual Politics
of Sickness (Old Westbury, N.Y.: The Feminist Press, 1973).

43. A. Flexner, Medical Education, pp. 26, 28-30.

44. Ibid., pp. 52-89.

45. Ibid., p. 16.

46. G. Frank Lydston, "Medicine as a Business Proposition," JAMA, 34 (1900),
1320.

47. JAMA, 37(1901), 1119.

48. "Council," JAMA, 44 (1905), 1471.

49. For further evidence of medical reformers' views on reducing output and raising
the profession's class base, see Chapter 2.

50. "Council," JAMA, 44 (1905), 1471.

51. Frederick C. Shattuck and J. Lewis Bremer, "The Medical School, 1869-1929,"
in S. E. Morison, ed., The Development of Harvard University Since the
Inauguration of President Eliot, 1869-1929 (Cambridge, Mass.: Harvard Uni-
versity Press, 1930), pp. 558-62. See also Frank BilUngs, "Medical Education in
the United States," President's Address, JAMA, 40 (1903), 1271-76, for a brief
summary of the organization's position on this and other planks in the reform
platform.

52. Pritchett to Bevan, Nov. 4, 1909, correspondence with AMA, Carnegie
Foundation files.

53. Pritchett to Bevan, June 18, 1910, and Bevan to Pritchett, Dec. 17, 1910,
correspondence with AMA, Carnegie Foundation files. The reviews of Flex-
ner's report were mixed. The New York Times (June 12, 1910) praised the
report but called it "slightly contentious and unnecessarily irritating." The
Chicago Daily Tribune (June 6 and 7, 1910) observed that schools that were
given favorable evaluations by Flexner praised his report while those that were
condemned by Flexner denied the validity of his report. The same paper noted
that "the recommendations lean toward depriving the poor man of an
education." American Medicine [5 (1910), 441-42] criticized the report for
saying little that was not already known in the medical profession and for
disregarding "the very evident progress of the past ten to fifteen years." The
journal wishfully asserted that "the day of the small, comparatively inconse-
quential medical college is by no means passed." The New York State Journal of
Medicine [10 (1910), 483-84] criticized the Carnegie Foundation for meddling in
the internal affairs of universities and colleges and attacked the Flexner report's
"wholesale and intemperate criticisms" of American medical schools. The
homeopathic medical sect, of course, joined the chorus of criticism" from

Notes to Pages 153-156 I 259

wounded professional interests; see the Homeopathic Recorder, 25 (1910),
241-43,337-39, 413,416; and 26 (1911), 15-16. The JAMA [54 (1910), 1949]
equally predictably praised the report and voiced the leadership's fervent hope
that "this report will call the attention of men of wealth to the need of endow-
ments for medical education."

54. Pritchett to N. P. Colwell, Dec. 29, 1913, correspondence with AMA, Carnegie
Foundation files.

55. Pritchett accused the council of giving greater leniency to Baylor University's
medical school than to Meharry. Pritchett to Colwell, April 3, 1918, and May 2,
1921, and other letters between Pritchett and Bevan from 1918 to 1922,
correspondence with AMA, Carnegie Foundation files. By 1917 Pritchett was so
disenchanted with the council, and presumably ashamed of his own gullibility a
decade earlier, that he rejected out of hand a request by Bevan that the
foundation undertake a new study designed to discredit "medical cults." Bevan
included in this term "everything that masquerades as branches or cults in the
art of healing outside of regular scientific medicine." Bevan to Pritchett, March
23, 1917; Pritchett to Bevan, April 3, 1917; and Clyde Furst, secretary of the
Carnegie Foundation, to N. P. Colwell, Dec. 1, 1917; all in correspondence with
AMA, Carnegie Foundation files.

56. A. Flexner, Autobiography, p. 165; Saul Jarcho, "Medical Education in the
United States, 1910-1956," Journal of the Mount Sinai Hospital, 26 (1959),
339^0.

57. A. Flexner, Medical Education, pp. 10-11.

58. On the impact of the Flexner report see Stevens, American Medicine, pp. 68-69;
Rothstein, American Physicians, pp. 292-94; Markowitz and Rosner, "Doc-
tors," 101; Robert P. Hudson, "Abraham Flexner in Perspective: American
Medical Education, 1865-1910," Bulletin of the History of Medicine, 46 (1972),
545-61; H. David Banta, "Abraham Flexner — A Reappraisal," Social Science
and Medicine, 5 (1971), 655-61; and Carleton B. Chapman, '"The Flexner
Report by Abraham Flexner," Daedalus, 103 (Winter 1974), 105-17. For a
thorough discussion of the Flexner report in its historical context, see Howard S.
Berhner, "A Larger Perspective on the Flexner Report," International Journal
of Health Services, 5 (1975), 573-92.

59. Herbert M. Morals, The History of the Negro in Medicine (New York^
Publishers Co., for Association for the Study of Negro Life and History, 1967),
pp. 86, 100. De facto segregation is still the reality in the North as well as in the
South. Black physicians serve a nearly all-black clientele while few white doctors
locate their offices in poor or racial minority areas. Cf. Lois C. Gray, "The
Geographic and Functional Distribution of Black Physicians: Some Research
and Policy Considerations," American Journal of Public Health, 67 (1977),
519-26; and Eva J. Salber et al., "Access to Health Care in a Southern Rural
Community," Medical Care, 14 (1976), 971-«6.

60. Quoted in John F. Fulton, Harvey Gushing, A Biography (Springfield, 111.:
Charles C. Thomas, 1946), p. 379. Bevan's memor)' did not serve him well (or
perhaps it served him better than it served truth). He remembered there being
twenty-two homeopathic schools and twelve eclectic schools "runnmg at the
time." The council's own figures indicate that there were twenty-two homeo-
pathic schools in 1900 and never more than nine eclectic schools at any one time
(although a total of thirty-two had been started during the previous century).

61. "Medical Education in the United States," JAMA, 79 (1922), 629-37.

62. Annual Report of the General Education Board, 1919-1920 and 1928-1929; and
Stevens, American Medicine, p. 69.

63. "The Art of Endowing Medical Colleges," JAMA, 37 (1901), 201.

260 I Notes to Pages 156-165

64. A. Flexner, Autobiography, pp. 109-10; R. B. Fosdick, Adventure in Giving,
The Story of the General Education Board (New York: Harper and Row, 1962),
pp. 154-55; and A. Flexner to F. T. Gates, June 24, 1911, GEB files,
Rockefeller Foundation Archives.

65. A. Flexner, Autobiography, pp. 110-11.

66. Ibid., pp. \l2-\3, Fosdick, Adventure, p. 157; A. Flexner, "From the Report on
the Johns Hopkins Medical School," GEB files, Rockefeller Foundation
Archives.

67. See George W. Corner, A History of the Rockefeller Institute, 1901-1953 (New
York: Rockefeller Institute Press, 1964), p. 94; and S. Flexner and J. T.
Flexner, William Henry Welch and the Heroic Age of American Medicine (New
York: Viking Press, 1941), p. 304. The policy was established before the
hospital opened in 1910.

68. F. T. Gates, "Concerning Private Gifts to States and a Medical Policy," Memo
to the General Education Board, Feb. 26, 1925, Gates collection, Rockefeller
Foundation Archives.

69. J. D. Greene to Dr. Henry A. Christian, Nov. 30, 1914, GEB files, Rockefeller
Foundation Archives.

70. Gates, "Private Gifts."

71. For descriptive history of full-time plan's origins, see Flexner and Flexner,
Welch, pp. 297-314, 320-28.

72. Richard H. Shryock, The Unique Influence of the Johns Hopkins University on
American Medicine (Copenhagen: Ejnar Munksgaard, Ltd., 1953), p. 19.

73. Donald Fleming, William H. Welch and the Rise of Modern Medicine (Boston:
Little, Brown and Co., 1954), especially p. 21; S. Flexner and J. T. Flexner,
Welch, pp. 71-72.

74. Quotes and information about Mall are from Florence R. Sabin, Franklin Paine
Mall, The Story of a Mind (Bahimore: Johns Hopkins Press, 1934), especially
pp. 29, 127-33, 203, 261, 264.

75. JAMA, 35 (1900), 501.

76. Victor C. Vaughan, "Reorganization of Clinical Teaching," JAMA, 64 (1915),
785-90.

77. Quoted in Sabin, Mall, p. 270.

78. Fosdick, Adventure, p. 160.

79. Stevens, American Medicine, p. 96.

80. Arthur D. Bevan, "Report of the Council on Medical Education," JAMA, 65
(1915), 110-11.

81. Benjamin Moore, "The Value of Research in the Development of National
Health," Popular Science Monthly, 85 (1914), 366.

82. Quoted in Ilza Veith and Franklin C. McLean, Medicine at the University of
Chicago, 1927-1952 (Chicago: University of Chicago Press, 1952), p. 22.

83. William H. Welch, "Report on the Endowment of University Medical Educa-
tion," 1911, copy in GEB files. Rockefeller Foundation Archives.

84. A. Flexner, Autobiography, pp. 114-15.

85. Welch's letter to GEB, quoted in Fosdick, Adventure, p. 158.

86. Ibid., p. 159.

87. William H. Welch to Simon Flexner, Dec. 5, 1915, GEB files, Rockefeller
Foundation Archives.

88. Quoted in S. Flexner and J. T. Flexner, Welch, p. 326. Janeway's article was
"Outside Professional Engagements by Members of Professional Faculties,"
published in Nicholas Murray Butler's journal. Educational Review, 55 (1918),
207-19.

89. Quoted in S. Flexner and J. T. Hexner, Welch, pp. 326-27.

Notes to Pages 165-173 / 261

90. A. Flexner to H. S. Pritchett, March 27, 1919, correspondence with GEB,
Carnegie Foundation files.

91. Fosdick, Adventure, p. 328.

92. Ibid., p. 180.

93. Fulton, Gushing, pp. 383-84; and Fosdick, Adventure, p. 163.

94. Fosdick, Adventure, p. 163; and Fulton, Gushing, pp. 377-84.

95. A. Flexner to W. Buttrick, May 7, 1921, GEB files. Rockefeller Foundation
Archives.

96. "Reasons Why the Harvard Medical School Offers the Best Opportunities for
Surgical Scientific Work," by "Members of the Surgical Department," attached
to letter from H. P. Bowditch (?) to John D. Rockefeller, Jr., Oct. 31, 1900,
Rockefeller Family Archives, record group 2.

97. Eliot quoted in Fosdick, Adventure, p. 163.

98. Ibid., p. 164.

99. Los Angeles Record, May 14, 1912; quoted in Catherine Lewerth, "Source
Book for a History of the Rockefeller Foundation" (tyjjewritten ms., bound in
21 vols., Rockefeller Foundation Archives, c. 1949), p. 23.

100. Bird S. Coler to Starr J. Murphy, April 19, 1917, and clipping from Brooklyn
Standard Union, April 12, 1917, Rockefeller Family Archives, record group 2.
Coler had strong Progressive leanings. He believed the foundation was driving
"an artificial line of division between the more fortunate minority and the less
fortunate majority of our people." In this respect he was clearly wrong since the
foundation was attempting to cover up the class divisions in the society.

101. Pittsburgh (Pa.) Leader, July 10, 1914, clipping enclosed in letter from Starr J.
Murphy to F. T. Gates, July 21, 1914, Rockefeller Family Archives, record
group 2.

102. Commission on Industrial Relations, Final Report (Washington, D.C.: Barnard
and Miller Print, 1915), pp. 116-19. See also James Weinstein, The Gorporate
Ideal in the Liberal State, 1900-1918 (Boston: Beacon Press, 1968), pp. 172-213.

103. G. F. Peabody to F. T. Gates, Nov. 5, 1911, Rockefeller Family Archives,
record group 2.

104. C. W. Eliot to F. T. Gates, March 27, 1914, Gates collection. Rockefeller
Foundation Archives.

105. F. T. Gates, memo to himself or the board (n.d., but apparently Nov. 1911),
Rockefeller Family Archives, record group 2.

106. George E. Vincent, The Rockefeller Foundation, A Review for 1917 (New
York: Rockefeller Foundation, 1918), p. 8; F. T. Gates to G. E. Vincent, March
20, 1918, and G. E. Vincent to F. T. Gates, March 25, 1918, Program and Policy
File, Rockefeller Foundation Archives, record group 1.

107. Fosdick, Adventure, p. 164.

108. Ibid., p. 164.

109. Lewerth, "Source Book," pp. 5116, 5119-21.

110. Quoted in ibid., p. 5115.

111. Annual Report of the General Education Board, 1920-1921 (New York: GEB,
1922), p. 22.

112. Lewerth, "Source Book," pp. 5115-16.

113. H. S. Pritchett to Wallace Buttrick, Feb. 11 and 24, 1919, correspondence with
GEB, Carnegie Foundation files.

114. Pritchett to Flexner, June 10, 1925, correspondence with GEB, Carnegie
Foundation files.

115. H. S. Pritchett to Wallace Buttrick, Nov. 11, 1919, correspondence with GEB,
Carnegie Foundation files.

262 I Notes to Pages 173-181

116. W. Buttrick to H. S. Pritchett, Nov. 21, 1919, correspondence with GEB,
Carnegie Foundation files.

1 17. W. Buttrick to Harry Pratt Judson, president of University of Chicago, Dec. 26,
1914, GEB files. Rockefeller Foundation Archives.

118. Correspondence regarding Columbia University medical school, 1917-1920,
GEB files, Rockefeller Foundation Archives; and W. Buttrick to H. S.
Pritchett, Nov. 21, 1919, correspondence with GEB, Carnegie Foundation files.

119. C. W. Eliot to W. Buttrick, April 24, 1917, GEB files. Rockefeller Foundation
Archives; and A. P. Stokes to A. Flexner, March 10, 1925, GEB files.
Rockefeller Foundation Archives. Stokes was always wary of public criticism
that the GEB was attempting to control educational institutions with its grants
(cf. A. P. Stokes to W. Buttrick, Jan. 29, 1917, GEB files. Rockefeller
Foundation Archives).

120. T. M. Debevoise to F. T. Gates, Oct. 7, 1925, GEB files, Rockefeller
Foundation Archives.

121. Ibid.

122. Minutes of the GEB, Feb. 26, 1925, GEB files. Rockefeller Foundation
Archives.

123. Minutes of the GEB Executive Committee, Sept. 30, 1925, GEB files,
Rockefeller Foundation Archives.

124. Commission on Medical Education, Supplement to the Third Report (New
Haven: Office of the Director of the Study, May 1929), p. 58.

125. Association of American Medical Colleges, Proceedings of the 17th Annual
Meeting, Washington, D.C., May 6, 1907, p. 17.

126. Commission on Medical Education, Supplement, pp. 58-59.

127. Memorandum, Dec. 1919, quoted in Fosdick, Adventure, p. 166.

128. Annual Report of the GEB, 1922-1923, pp. 17-19.

129. Fosdick, Adventure, pp. 166-67.

130. F. T. Gates to A. Flexner, Dec. 2, 1922; quoted in Lewerth, "Source Book,"
pp. 5230-31; and Gates memo, quoted in Fosdick, Adventure, p. 167.

131. A. Hexner, Autobiography, p. 189; A. Flexner to H. S. Pritchett, Nov. 1, 1922;
quoted in Fosdick, Adventure, p. 167.

132. Lewerth, "Source Book," p. 5231.

133. Gates, "Private <}ifts."

134. Ibid.

135. Ibid.

136. Gates, Autobiography, unpublished ms., 1928, Gates collection. Rockefeller
Foundation Archives, p. 463; Gates, "Some Reflections on Questions of
Policy," memo to the board, Jan. 23, 1906, Gates collection. Rockefeller
Foundation Archives.

137. Ibid.

138. Ibid.

139. Ibid.

140. Ibid.

141. Ibid.

142. Ibid.

143. Gates, memo "written for the sake of clarifying my own thought" concerning
conflicts he was having with board member Charles W. Eliot over GEB funding
policies. Eliot favored using some funds to support current expenses of colleges
as opposed to Gates' insistence on permanent endowments. He criticized Eliot's
conception of the board's mission as much too "humble." "Dr. Eliot's plan is to
buy [apples] at a dollar a bushel and distribute them. My plan is to plant apple
trees." Memo, Feb. 28, 1910, Rockefeller Family Archives, record group 2.

Notes to Pages 181-195 I 263

144. See E. Richard Brown, "Public Health in Imperialism: Early Rockefeller
Programs at Home and Abroad," American Journal of Public Health, 66 (1976),
897-903.

145. Gates, Autobiography, pp. 456-57, 463-64.

146. Gates, "Fundamental Principles of Mr. Rockefeller's Philanthropy," Oct. 7,
1908, Gates collection. Rockefeller Foundation Archives.

147. Gates to Rockefeller, St., Aug. 9, 1907, Gates collection. Rockefeller Founda-
tion Archives.

148. Gates, "Thoughts on the Rockefeller Public and Private Benefactions," Dec.
31, 1926, Gates collection, Rockefeller Foundation Archives.

149. Fosdick, The Story of the Rockefeller Foundation (London: Odhams Press,
Ltd., 1952), p. 117.

150. Annual Report of the GEB, 1920-1921, pp. 30-34.

151. Gates, "Private Gifts."

152. Minutes of the GEB, Nov. 1924 through March 1925; and W. Buttrick to J. D.
Rockefeller, Jr., Dec. 29, 1924, GEB files. Rockefeller Foundation Archives.

153. Minutes of the board. May 28, 1925; and Document of Record no. 474, GEB
files, Rockefeller Foundation Archives.

154. Minutes of the GEB Executive Committee, Nov. 9, 1925, GEB files, Rockefel-
ler Foundation Archives.

155. Lewerth, "Source Book," p. 5240, based on correspondence between Iowa
officers. Rockefeller and GEB officers, and Pritchett at Carnegie Foundation.

156. On the development of monopoly control through intervention by the State, see
Gabriel Kolko, The Triumph of Conservatism — A Reinterpretation of American
History, 1900-1916 (Chicago: Quadrangle Books, 1967); and Weinstein, The
Corporate Ideal.

157. David Rockefeller quote from Wall Street Journal, Dec. 21, 1971, p. 10.

158. JAMA, 37 (1901), 200-01.

159. A. D. Bevan to H. S. Pritchett, Oct. 5, 1921, correspondence with AMA,
Carnegie Foundation files.

160. W. H. Welch, "Duties of a Hospital to the Public Health," Proceedings of the
National Conference of Charities and Correction, 42nd Annual Meeting,
Baltimore, May 12-19, 1915, p. 215.

161. Markowitz and Rosner, "Doctors," 87.

162. The history of the AMA's involvement with social insurance from 1915 to 1920
is developed in Elton Rayack, Professional Power and American Medicine (New
York: World Publishing Co., 1967), pp. 136-46; and Burrow, AMA, pp.
132-51. Other views of the ascendancy of the conservatives in the AMA in 1920
can be found in Shryock, Licensing, pp. 91-94; and in Stevens, American
Medicine.

CHAPTER 5

1. Rosemary Stevens, American Medicine and the Public Interest (New Haven:
Yale University Press, 1971), pp. 68-69; and Richard H. Shryock, American
Medical Research, Past, and Present (New York: Commonwealth Fund, 1947),
pp. 96-97.

2. Abraham Flexner, Abraham Flexner: An Autobiography (New York: Simon
and Schuster, 1960), p. 37.

3. Committee on the Costs of Medical Care, Medical Care for the American
People: The Final Report of the Committee on the Costs of Medical Care
(Chicago: University of Chicago Press, 1932).

264 I Notes to Pages 196-203

4. Although one-third of the committee's membership was private practitioners,
two-thirds were persons generally committed to rationalizing medical care,
including Secretary of the Interior Ray Lyman Wilbur and Winthrop W.
Aldrich, president of the Chase National Bank and brother-in-law of John D.
Rockefeller, Jr. For other discussions of the CCMC, see Odin W. Anderson,
The Uneasy Equilibrium: Private and Public Financing of Health Services in the
United States, 1875-1965 (New Haven: College and University Press, 1968), pp.
91-103; and Elton Rayack, Professional Power and American Medicine: The
Economics of the American Medical Association (Cleveland: World Publishing
Co., 1967), pp. 146-55.

5. JAMA, 99 (1932),' 1950-52. See also Rayack, noted above.

6. I. S. Falk, "Medical Care in the U.S.A.: 1932-1972. Problems, Proposals, and
Programs from the Committee on the Costs of Medical Care to the Committee
for National Health Insurance," Health and Society, Milbank Memorial Fund
Quarterly, 51 (Winter 1973), 6, 15.

7. Leonard Rodberg and Gelvin Stevenson, "The Health Care Industry in Ad-
vanced Capitalism," Review of Radical Political Economics, 9 (Spring 1977),
104-15.

8. Edwin R. Embree and Julia Waxman, Investment in People: The Story of the
Julius Rosenwald Fund (New York: Harper and Bros., 1949), pp. 128-31.

9. For a thorough examination of Blue Cross, see Sylvia Law, Blue Cross: What
Went Wrong? (New Haven: Yale University Press, 1974). For a brief history of
Blue Cross, Blue Shield, and insurance company involvement in commercial
health insurance, see Herman M. Somers and Anne R. Somers, Doctors,
Patients, and Health Insurance — The Organization and Financing of Medical
Care (Washington, D.C.: Brookings Institution, 1961), pp. 249-340. For later
data on premium income, see Robert M. Gibson and Charles R. Fisher,
"National Health Expenditures, Fiscal Year 1977," Social Security Bulletin, 41
(July 1978), 3-20.

10. For a summary of information on the Hill-Burton program, see Cambridge
Research Institute, Trends Affecting the U.S. Health Care System (Washington,
D.C.: Government Printing Office, 1976), pp. 91-95.

11. See, for example, G. William Domhoff, The Higher Circles: The Governing
Class in America (New York: Vintage Books, 1971); Ralph Miliband, The State
in Capitalist Society (New York: Basic Books, 1969); Claus Offe, "Political
Authority and Class Structures: An Analysis of State Capitalist Societies,"
International Journal of Sociology, 2 (1972), 73-108; and James O'Connor, The
Fiscal Crisis of the State (New York: St. Martin's Press, 1973). For analyses of
the State and health care under capitalism, see Marc Renaud, "On the
Structural Constraints to State Intervention in Health," International Journal of
Health Services, 5 (1975), 559-71; and Vincente Navarro, Medicine Under
Capitalism (New York: Prodist, 1976), pp. 183-228.

12. See Rayack, Professional Power, chap. 5; and James G. Burrow, AMA, Voice
of American Medicine (Baltimore: Johns Hopkins Press, 1963), chap. 7.

13. Rayack, Professional Power, chap. 5; and Burrow, AMA, pp. 194-251,
293-301, 340-71.

14. Rayack, Professional Power, chap. 3.

15. Gibson and Fisher, "National Health Expenditures"; and Hospital Statistics,
1977 ed. (Chicago: American Hospital Association, 1977).

16. See, for example, Barry Ensminger, "The $8-Billion Hospital Bed Overrun: A
Consumer's Guide to Stopping Wasteful Construction" (Washington, D.C.:

Notes to Pages 203-210 / 265

Public Citizen's Health Research Group, 1975); and Institute of Medicine,
Controlling the Supply of Hospital Beds (Washington, D.C.: National Academy
of Sciences, 1976).

17. Cambridge Research Institute, Trends, p. 180.

18. Gibson and Fisher, "National Health Expenditures."

19. Robert Alford, Health Care Politics: Ideological and Interest Group Barriers to
Reform (Chicago: University of Chicago Press, 1975), especially pp. 190-217.

20. Hospital Statistics, pp. 4-5.

21. See, for example, Douglass J. Seaver, "Hospital Revises Role, Reaches Out to
Cultivate and Capture Markets," Hospitals, 51 (June 1, 1977), 59-63; David D.
Karr, "Increasing a Hospital's Market Share," in same issue, 64-66; and Warren
C. Falberg and Shirley Bonnem, "Good Marketing Helps a Hospital Grow," in
same issue, 70-73.

22. Bureau of the Census, Statistical Abstract of the United States, 1976 (Washing-
ton, D.C.: Government Printing Office, 1976), p. 427.

23. Navarro, Medicine Under Capitalism, pp. 148-49.

24. Marianna O. Lewis, ed. The Foundation Directory, 6th ed. (New York:
Foundation Center, 1977), pp. xiii, xxi.

25. See, for example, G. WilHam Domhoff, Who Rules America? (Englewood
Cliffs, N.J.: Prentice-Hall, 1967); and Domhoff, The Higher Circles.

26. Vicente Navarro, "National Health Insurance and the Strategy for Change,"
Health and Society, Milbank Memorial Fund Quarterly, 51 (Spring 1973),
236-37.

27. See, for example, David Mechanic, Public Expectations and Health Care (New
York: Wiley-Interscience, 1972), p. 27.

28. Eliot Marshall, "What's Bad for General Motors," New Republic, March 12,
1977, pp. 22-23.

29. Gibson and Fisher, "National Health Expenditures."

30. From the voluminous literature on HMOs, some useful favorable articles are:
Cambridge Research Institute, Trends, pp. 221-60; Ernest W. Saward and
Merwyn R. Greenlick, "Health Policy and the HMO," Milbank Memorial Fund
Quarterly, 50 (April 1972, pt. 2), 147-76; Ira G. Greenberg and Michael L.
Rodburg, "The Role of Prepaid Group Practice in Relieving the Medical Care
Crisis," Harvard Law Review, 84 (1971), 887-1001. The business point of view,
also very favorable, is represented by Committee for Economic Development,
Building a National Health Care System (New York: Committee for Economic
Development, 1973); Michael B. Rothfield, "Sensible Surgery for Swelling
Medical Costs," Fortune, (April 1973), 110-19; and "Containing the Cost of
Employee Health Plans," Business Week, May 30, 1977, pp. 74-76. Some good
critical articles on HMOs include Howard B. Waitzkin and Barbara Waterman,
The Exploitation of Illness in Capitalist Society (Indianapolis, Ind.: Bobbs-
Merrill, 1974), pp. 89-107; Thomas Bodenheimer, Elizabeth Harding, and
Steve Cummings, Billions for Band- Aids (San Francisco: Medical Committee
for Human Rights, 1972), pp. 75-98; and Judy Carnoy et al., "The Kaiser
Plan," Health PAC Bulletin, no. 55, Nov. 1973, pp. 1-18. The enabling and
funding legislation is the Health Maintenance Organization Act of 1973 (P.L.
93-222).

31. JAMA, 227(1974), 1171.

32. See, for example, Bruce C. Vladeck, "Interest-Group Representation and the
HSAs: Health Planning and Political Theory," American Journal of Public
Health, 67 (1977), 23-39.

33. Committee for Economic Development, Building a National Health Care
System.

266 I Notes to Pages 210-219

34. Lewis, Foundation Directory, p. xxi; and David E. Rogers, "The President's
Statement," Robert Wood Johnson Foundation Annual Report, 1973 (Prince-
ton, N.J.: Robert Wood Johnson Foundation, 1973).

35. Alford, Health Care Politics, pp. 190-217.

36. Falk, "Medical Care in the U.S.A.," 29-30 (emphasis added).

37. Recent legislative efforts to control rising hospital costs led to conflicts among
hospitals, which were concerned mainly with limitations on their revenues, and
investment bankers and medical equipment manufacturers, who were upset with
limitations on capital expenditures that would reduce hospital construction and
purchase of major equipment such as CAT scanners. See "Bankers and
Manufacturers Meet to Discuss Opposition to Hospital Cost Containment,"
Washington Report on Medicine and Health, 31 (Aug. 29, 1977), 2.

38. Alford, Health Care Politics, p. 193.

39. Health United States, 1975 (Rockville, Md.: National Center for Health
Statistics, 1976), pp. 405, 409; Lu Ann Aday, "The Impact of Health Policy on
Access to Medical Care," Health and Society, Milbank Memorial Fund
Quarterly, 54 (Spring 1976), 215-33; Ronald Andersen, Joanna Kravits, and.
Odin W. Anderson, Equity in Health Services: Empirical Analyses in Social
Policy (Cambridge, Mass.: Ballmger Publishing Co., 1975), p. 178; Adele D.
Hofmann, "Health Care of Inner-City Adolescents," Clinical Pediatrics, 13
(1974), 570-73; A. F. Brunswick and E. Josephson, "Adolescent Health in
Harlem," American Journal of Public Health, 62 (1972, suppl), 1-62; K. D.
Rogers and G. Reese, "Health Studies — Presumably Normal High School
Students," American Journal of Diseases of Children, 108 (1964), 572-600; and
Health Attitudes and Behaviors of Youths 12-17 Years: Demographic and
Socioeconomic Factors, Vital and Health Statistics, series 11, no. 153 (Washing-
ton, D.C.: National Center for Health Statistics, 1975).

40. San Francisco Chronicle, July 14, 1977.

41. Lois C. Gray, "The Geographic and Functional Distribution of Black Physi-
cians: Some Research and Policy Considerations," American Journal of Public
Health, 67 (1977), 519-26. See also Eva J. Salber et al., "Access to Health Care
in a Southern Rural Community," Medical Care, 14 (1976), 971-86.

42. Cambridge Research Institute, Trends, p. 128.

43. Marjorie Smith Mueller, "Private Health Insurance in 1973: A Review of
Coverage, Enrollment, and Financial Experience," Social Security Bulletin, 38
(Feb. 1975), 21^0.

44. Gibson and Fisher, "National Health Expenditures."

45. Quoted in L. Frederick, "How Much Unnecessary Surgery?" Medical World
News, 17 (1976), 50-66.

46. John P. Bunker, "Surgical Manpower: A Comparison of Operations and
Surgeons in the United States and in England and Wales," New England
Journal of Medicine, 282 (1970), 135-^.

47. House Committee on Interstate and Foreign Commerce, Cost and Quality of
Health Care: Unnecessary Surgery ^Washington, D.C.: Government Printing
Office, 1976).

48. R. D. Lyons, "Surgery on Poor Is Found Higher," New York Times, Sept. 1,
1977.

49. Cambridge Research Institute, Trends, p. 366.

50. Ibid., pp. 357-66.

51. On the commodification of health services, see Navarro, Medicine Under
Capitalism, pp. 183-228; and Rodberg and Stevenson, "Health Care Industry."

52. See, for example, Harry Schwartz, The Case for American Medicine (New

Notes to Pages 219-222 I 267

York: David McKay, 1972); and his article, "A Half Century of Health
Progress," Ohio State Medical Journal, 71 (1975), 58-59.

53. T. McKeown, "A Conceptual Background for Research and Development in
Medicine," International Journal of Health Services, 3 (1971), 17-28; and
McKeown, Medicine in Modern Society (London: Allen & Unwin, 1965).

54. Warren Winkelstein and Fern E. French, "The Role of Ecology in the Design of
a Health Care System," California Medicine, 113 (1970), 7-12.

55. John Powles, "On the Limitations of Modern Medicine," Science, Medicine,
and Man, 1 (1973), 6. For similar data, analysis, and conclusions applied to the
United States, see John B. McKinlay and Sonja M. McKinlay, "The Questiona-
ble Contribution of Medical Measures to the Decline of Mortality in the United
States in the Twentieth Century," Health and Society I Milbank Memorial Fund
Quarterly (Summer 1977) 405-28.

56. Rene Dubos, Mirage of Health— Utopias, Progress, and Biological Change
(Garden City, N.Y.: Anchor Books, 1959), pp. 30-31.

57. George Rosen, A History of Public Health (New York: M D Publications,
1958), pp. 192-275; and Dubos, Mirage of Health, pp. 139^0.

58. Health United States, 1975, pp. 227, 358-59.

59. C. L. Erhardt and J. E. Berlin, eds.. Mortality and Morbidity in the United
States (Cambridge, Mass.: Harvard University Press, 1974), p. 174; and Health
United States, 1975, pp. 338-47, 371.

60. Barbara Starfield, Health Needs of Children, Harvard Child Health Series
Project Reports, vol. 2 (Cambridge, Mass.: Harvard University Press, 1976);
and Erhardt and Berlin, Mortality and Morbidity, pp. 28-29.

61. Harold S. Luft, "The Probability of Disability: The Influence of Age, Race,
Sex, Education, and Income," Paper presented at Annual Meeting of the
American Public Health Association, Chicago, November 17, 1975; and
"Socioeconomic Differentials in Morbidity," Metropolitan Life Insurance Com-
pany Statistics Bulletin, 53 (June 1972), 10-12.

62. S. Leonard Syme and Lisa F. Berkman, "Social Class, Susceptibility, and
Sickness," American Journal of Epidemiology, 104 (1976), 1-8; M. H. Nagi and
E. G. Stockwell, "Socioeconomic Differentials in Mortality by Cause of
Death," Health Services Reports, 88 (1973), 449-56; A. Antonovsky, "Social
Class, Life Expectancy, and Overall Mortality," Milbank Memorial Fund
Quarterly, 45 (1967), 31-73; Stephanie J. Ventura et al., "Selected Vital and
Health Statistics in Poverty and Nonpoverty Areas of 19 Large Cities, United
States, 1969-71," Vital and Health Statistics, series 21, no. 26 (Rockville, Md.:
National Center for HeaUh Statistics, 1975).

63. Warren Winkelstein, "Epidemiological Considerations Underlying the Alloca-
tion of Health and Disease Care Resources," International Journal of Epidemi-
ology, 1 (1972), 69-74.

64. Winkelstein and French, "The Role of Ecology"; and G. A. Lillington, "Health
Effects from Air Pollution," in W. D. McKee, ed.. Environmental Problems in
Medicine (Springfield, 111.: Charles C. Thomas, 1974), pp. 314-24.

65. See Forward Plan for Health, [Fiscal Year] 1978-82 (Washington, D.C.: Public
Health Service, 1976), p. 77; Daniel M. Berman, Death on the Job (forthcoming
from Monthly Review Press), chap. 2; J. A. Page and M. O'Brien, Bitter Wages
(New York: Grossman, 1973); and P. Brodeur, Expendable Americans (New
York: Viking Press, 1974).

66. Blue Cross Association Consumer Report, March 1976, p. 1.

67. J. Eyer, "Hypertension as a Disease of Modern Society," International Journal
of Health Services, 5 (1975), 539-58; S. L. Syme, T. Oakes, and G. Friedman,

268 I Notes to Pages 223-227

"Social Class and Racial Differences in Blood Pressure," American Journal of
Public Health, 64 (1974), 619-20; S. L. Syme, M. M. Hyman, and P. E.
Enterline, "Cultural Mobility and the Occurrence of Coronary Heart Disease,"
Journal of Health and Human Behavior, 6 (1965), 178-90; M. Friedman, R.
Rosenman, and V. Carroll, "Changes in Serum Cholesterol and Blood Clotting
Time in Men Subjected to Cyclic Variation of Occupation Stress," Circulation,
17 (1958), 852-61; H. Russek and B. Zohman, "Relative Significance of
Heredity, Diet, and Occupational Stress in Coronary Heart Disease of Young
Adults," American Journal of Medical Science, 235 (1958), 266-77; M.
Friedman and R. Rosenman, Type A Behavior and Your Heart (New York:
Knopf, 1974); and S. Kasl and S. Cobb, "Blood Pressure Changes in Men
Undergoing Job Lx)ss: A Preliminary Report," Psychosomatic Medicine, 32
(1970), 19-38.

68. Erhardt and Berlin, Mortality and Morbidity, pp. 28-29.

69. Special Task Force to the Secretary of Health, Education, and Welfare, Work in
America (Cambridge, Mass.: MIT Press, 1973), pp. 77-79.

70. Robert J. Haggerty, "Session III — Present Strengths and Weaknesses in
Current Systems of Comprehensive Health Services for Children and Youth,"
American Journal of Public Health, 60 (1970), 74-98.

71. Walsh McDermott, Kurt W. Deuschle, and Clifford R. Bamett, "Health Care
Experiment at Many Farms," Science, 175 (1972), 23-31.

72. Joel Alpert et al., "Delivery of Health Care for Children: Report of an
Experiment," Pediatrics, 57 (1976), 917-30.

73. Paul Starr, "Who Needs Medicine? The Politics of Therapeutic Nihilism,"
Working Papers for a New Society, 4 (Summer 1976), 48-55.

74. U.S. Congress, Office of Technology Assessment, Development of Medical
Technology — Opportunities for Assessment (Washington, D.C.: Government
Printing Office, 1976), pp. 14-15.

75. David M. Kessner et al. , Infant Death: An Analysis by Maternal Risk and Health
Care (Washington, D.C.: Institute of Medicine, National Academy of Sciences,
1973), pp. 1-18.

76. Naomi M. Morris et al., "Shifting Age-Parity Distribution of Births and the
Decrease in Infant Mortality." American Journal of Public Health, 65 (1975),
359-62.

77. Shryock, American Medical Research, pp. 96-97; and General Education Board
Annual Report, 1940, pp. 191-96.

78. Shryock, American Medical Research, pp. 277, 289.

79. Basic Data Relating to the National Institutes of Health, 1974 and 1977 eds. ; S. P.
Strickland, "Integration of Medical Research and Heahh Policies," Science, 173
(1971), 1093; Strickland, Science, Politics, and Dread Disease (Cambridge,
Mass.: Harvard University Press, 1972); and NIH Study Committee, Biomedical
Science and Its Administration, A Study of the National Institutes of Health
(Washington, DC: The White House, 1965).

80. American Foundation, Medical Research: A Midcentury Survey, vol. 1 (Boston:
Little, Brown and Co., 1955), 144, 147; and David E. Rogers, "Medical
Academe and the Problems of Primary Care," Journal of Medical Education, 50
(Dec. 1975, pt. 2), 171-80. In 1967-68, federal support equaled 53 percent of
U.S. medical schools' operating income, state and local government support
totaled another 15 percent, while tuition and fees came to only 4 percent and
endowment income to only 3 percent; see Ray E. Brown, "Financing Medical
Education," in William G. Anlyan et al. , eds. , The Future of Medical Education
(Durham, N.C.: Duke University Press, 1973), p. 180.

81. Rogers, "Medical Academe"; Herman M. Somers and Anne R. Somers,

Notes to Pages 227-233 I 269

Doctors, Patients, and Health Insurance (Washington, D.C.: Brookings Institu-
tion, 1961), p. 42; and James W. Begun, "Refining Physician Manpower Data,"
Medical Care, 15 (1977), 780-86.

82. See Barbara Ehrenreich and John Ehrenreich, The American Health Empire:
Power, Profits, and Politics (New York: A Heahh-PAC Book, Vintage Books,
1971); and Cecil G. Sheps and Conrad Seipp, "The Medical School, Its Products
and Its Problems," Annals of the American Academy of Political and Social
Science, 399 (Jan. 1972), 38-49.

83. Hans Zinsser, "The Perils of Magnanimity: A Problem in American Educa-
tion," Atlantic Monthly, 159 (1927), 246-50; see also the short article by the
director of the National Science Foundation, WiUiam D. McElroy, "The
Making of Science Policy," Proceedings of the Federation of American Societies
for Experimental Biology, 31 (1972), 1553-55.

84. JAMA, 37 (1901), 200-01, warned, "Rich men may injure the cause of medical
education" unless their giving is guided by the private practice medical
profession.

85. Basic Data Relating to the National Institutes of Health, 1977 ed.

86. American Foundation, Medical Research, vol. I, 11, 108-10, 132.

87. Basic Data Relating to the National Institutes of Health, 1974 and 1977 eds.

88. Forward Plan for Health, FY I978-S2, p. 97; Daniel S. Greenberg, " 'New
Broom' at the Cancer Institute?" New England Journal of Medicine, 297
(1977), 679-80; Samuel S. Epstein, "Environmental Determinants of Human
Cancer," Cancer Research, 34 (1974), 2425-35; and Los Angeles Times, Sept.

12, 1978.

89. Greenberg, " 'New Broom' "; and Greenberg, "The 'War on Cancer': Official
Fictions and Harsh Facts," Science and Government Report, 4 (Dec. 1, 1974),
1-3. See also Forward Plan for Health, FY 1978-82, p. 97. Other researchers
have concluded that some of the improvements in cancer survival rates with
most kinds of therapy are due to deficient tumor registry methods: Ralph D.
Reynolds et al., "Survival in Lung Cancer," Western Journal of Medicine, 121
(1977), 190-94. There have been some notable improvements in detection and
treatment of cancer (particularly for Hodgkin's disease and childhood leuke-
mia), but these have had very little impact on overall cancer mortality and, of
course, no impact on the incidence of cancer.

90. Forward Plan for Health, FY 1978-82, p. 96; and Vicente Navarro, "The
Underdevelopment of Health in Working America: Causes, Consequences, and
Possible Solutions," American Journal of Public Health, 66 (1976), 538-47.

91. Zachary Y. Dyckman, A Study of Physicians' Fees (Washington, D.C.:
President's Council on Wage and Price Stability, 1978), pp. 74-75.

92. Office of Technology Assessment, Development of Medical Technology, pp.
80-87; Basic Data Relating to the National Institutes of Health, 1977 ed.

93. Office of Technology Assessment, Development of Medical Technology, pp.
80-81 and 85; see also Milton Silverman and Philip R. Lee, Pills, Profits, and
Politics (Berkeley: University of California Press, 1974).

94. Office of Technology Assessment, Development of Medical Technology, pp. U,

27.

95. Ibid., pp. 11-13, 20, 27. See also James L. Goddard, "The Medical Business,"
in Scientific American, eds. , Life and Death and Medicine (San Francisco: W. H.
Freeman and Co., 1973), pp. 120-25; David A. Loehwing, "Biomedical
Technology — All Systems Are Go," Barron's, Nov. 5, 1973; and Loehwing,
"Biomedicine Abounds in Risks as Well as Rewards," Barron's, Nov. 12, 1973;
and Eliot Marshall, "Rendezvous with a Machine," New Republic, March 19,
1977, pp. 16-19.

270 / Notes to Pages 234-236

96. David E. Rogers, "On Technologic Restraint," Archives of Internal Medicine,
135 (1975), 1393-97.

97. Anne R. Somers, "Health Care and the Political System: The Sorcerer's
Apprentice Revisited," in Technology and Health Care Systems in the 1980s
(Rockville, Md.: National Center for Heahh Services Research and Develop-
ment, 1973), p. 39.

98. Basic Data Relating to the National Institutes of Health, 1974 and 1977 eds.

99. Victor R. Fuchs, "The Growing Demand for Medical Care," New England
Journal of Medicine, 279 (1968), 190-95.

100. Dubos, Mirage of Health.

101. Ivan Illich, Medical Nemesis: The Expropriation of Health (New York:
Pantheon, 1976).

102. Marc Lalonde, A New Perspective on the Health of Canadians (Ottawa:
Government of Canada, 1974).

103. On the Hmits of modern medicine, in addition to Illich, see A. L. Cochrane,
Effectiveness and Efficiency: Random Reflections on Health Services (London:
Nuffield Provincial Hospital Trust, 1972); Rick J. Carlson, The End of Medicine
(New York: John Wiley, 1975); Victor Fuchs, Who Shall Live? Health,
Economics, and Social Choice (New York: Basic Books, 1974); McKeown,
"Conceptual Background"; McKeown, Medicine in Modern Society; and
Powles, "On the Limitations of Modern Medicine." On medicine as social
control, in addition to Illich, see Barbara Ehrenreich and John Ehrenreich,
"Medicine and Social Control," and Irving Kenneth Zola, "Medicine as an
Institution of Social Control," both reprinted in John Ehrenreich, ed.. The
Cultural Crisis of Modern Medicine (New York: Monthly Review Press, 1978),
pp. 39-79 and 80-100, respectively; Waitzkin and Waterman, Exploitation of
Illness, pp. 16-65. See also the classic works of Talcott Parsons, The Social
System (New York: Free Press, 1951), and "Definitions of Health and Illness in
the Light of American Values and Social Structure," in E. G. Jaco, ed.,
Patients, Physicians, and Illness, 2nd ed. (New York: Free Press, 1972), pp.
107-127; and of Thomas Szasz, The Myth of Mental Illness (New York: Harper
and Row, 1961).

104. Nedra B. Belloc and Lester Breslow, "Relationship of Physical Health Status
and Health Practices," Preventive Medicine, 1 (1972), 409-21.

105. Fuchs, Who Shall Live? p. 46. For some epidemiological evidence to the
contrary, see discussion earlier in this chapter (pp. 219-23) and accompanying
references.

106. For critical reviews of this literature, see Robert Crawford, "You Are
Dangerous to Your Health: The Ideology and Politics of Victim Blaming,"
International Journal of Health Services, 1 (1977), 663-80; Navarro, Medicine
Under Capitalism, pp. 103-31; and Howard S. Berhner, "Emerging Ideologies
in Medicine," Review of Radical Political Economics, 9 (Spring 1977), 116-24.

107. J. W. Meigs, "Can Occupational Health Concepts Help Us Deal with
Childhood Lead Poisoning?" American Journal of Public Health, 62 (1972),
1483-85.

108. Pranab Chatterjee and Judith H. Gettman, "Lead Poisoning: Subculture as a
Facilitating Agent?" American Journal of Clinical Nutrition, 25 (1972), 324-30.

109. Conference on Future Directions in Health Care: The Dimensions of Medicine,
Sponsored by Blue Cross Association, Rockefeller Foundation, and University
of California (San Francisco) Health Policy Program, New York, Dec. 1975,
pp. 4-5.

110. Ibid., pp. 2-3.

111. Fuchs, Who Shall Live? p. 27.

Notes to Pages 236-238 I 271

112. Leon R. Kass, "Regarding the End of Medicine and the Pursuit of Health,"
Public Interest, no. 40 (Summer 1975), 39, 42.

113. See, for example, E. A. Suchman, "Social Patterns of Illness and Medical
Care," in E. G. Jaco, ed., Patients, Physicians, and Illness, pp. 262-79; S. S.
Kegeles et al., "Survey of Beliefs About Cancer Detection and Taking
Papanicolaou Test," Public Health Reports, 80 (1965), 815-24; and W. A.
Wingert et al., "Effectiveness and Efficiency of Indigenous Health Aids in a
Pediatric Outpatient Department," American Journal of Public Health, $a65
(1975), 849-57.

114. M. R. Greenlick et al., "Comparing the Use of Medical Care Services by a
Medically Indigent and a General Membership Population in a Comprehensive
Prepaid Group Practice Program," Medical Care, 10 (1972), 187-200; Alpert et
al., "Delivery of Health Care for Children"; R. J. Haggerty, K. J. Roghmann,
and I. B. Pless, Child Health and the Community (New York: John Wiley,
1975); and C. H. Goodrich, M. Olendzki, and G. Reader, Welfare Medical
Care: An Experiment (Cambridge, Mass.: Harvard University Press, 1970). See
also C. K. Reissman, "The Use of Health Services by the Poor," Social Policy, 5
(May-June 1974), 41^9; and John B. McKinlay and Diana B. Dutton,
"Social-Psychological Factors Affecting Health Service Utilization," in S. J.
Mushkin, ed.. Consumer Incentives for Health Care (New York: Prodist, 1974),
pp. 251-303, for reviews of the issue and the literature. The myths about why
patients break medical appointments are corrected in Philip Hertz and Paula L.
Stamps, "Appointment-Keeping Behavior Re-Evaluated," American Journal of
Public Health, 67 (1977), 1033-36.

115. For an example of such a program, see the article by California Governor
Ronald Reagan's head of the state's Health and Welfare Agency, Earl W.
Brian, "Government Control of Hospital Utilization — A California Experi-
ence," New England Journal of Medicine, 286 (1972), 1340-44.

116. C. Arden Miller, "Societal Change and Public Health: A Rediscovery,"
American Journal of Public Health, 66 (1976), 54-60.

117. See Crawford, "You Are Dangerous to Your Health," pp. 673-74, especially
quote from former UAW president Leonard Woodcock. For another example
of such a program, see report on the Department of Labor's "Employee Health
Program," an alcohol treatment program designed to "stabilize work behavior,"
in C. J. Schramm, "Measuring the Return on Program Costs: Evaluation of a
Multi-Employer Alcoholism Treatment Program," American Journal of Public
Health, 67 (1977), 50-:-i.

118. E. Richard Brown and Glen E. Margo, "Health Education: Can the Reformers
Be Reformed?" International Journal of Health Services, 8 (1978), 3-26.

Index

Abel, John J., 145
Addams, Jane, 23
AFL-CIO, 216
Agassiz, Louis, 26
Aldrich, Nelson, 48
Aldrich, Winthrop W., 264n4
Alford, Robert, 7, 204, 212
Allopathic medicine, 110, 218
American Academy of Medicine, 137
American Association for Labor Legisla-
tion, 117, 191, 201
American Baptist Education Society,

34-35, 36, 40, 124, 172
American Cancer Society, 219, 229
American College of Surgeons, 94
American Congress of Physicians and Sur-
geons, 93, 137
American Hospital Association, 7, 199,

204,216
American Medical Association (AMA), 5,
6
black and women doctors and, 88-89
Carnegie Foundation and, 152-53
codes of ethics, 66
Committee on Costs of Medical Care

and, 197
federal funding of medical research

and, 226
federal aid to medical schools and, 202,

226
founding, 65

full-time plan and, 163-64, 190
health insurance and, 191
Hill-Burton Act and, 199

medical education reform and, 65-66,
69, 85, 188

medical schools and, 8

attacks on medical sects, 66, 88-90

Medicare and Medicaid and, 202-03

membership, 93, 137, 138

national health insurance and, 197,
201-02,209,216,217

organization, 66-67, 83, 94, 137

as profession's political instrument, 67,
83,84

Professional Standards Review Organ-
izations and, 209

Progressivism and, 191

reorganization, 137-38

specialization and, 93-94

see also Council on Medical Education
American Public Health Association, 216
Angell, James, 184
Amett, Trevor, 184
Arnold, Richard, 113-14
Association of American Medical Col-
leges, 86, 89, 140, 176
Association of American Physicians, 93
Austria, 72, 81

Bache, Alexander Dallas, 25
Baldwin, William H., 57, 247n7/
Barker, Lewellys P., 158, 160, 164
Baylor University medical school, 259n55
Behring, Emil von, 76
Bellevue Hospital medical school, 72, 102
Bemis, Edward, 57

274 / Index

Bevan, Arthur Dean

appointment to Council on Medical
Education, 139

A. Flexnerand, 152, 155

Flexner report and, 143, 145, 151-52,
155

on full-time plan, 162, 190

General Education Board and, 190

on need for philanthropy to medical
schools, 142

Pritchett and, 143, 144, 151-53, 155,
190, 259n55

request to Carnegie Foundation, 142-43

role in professionalization campaign,
140-41

state licensing boards and, 139
Bigelow, Horatio. 92
Billings, Frank, 86
Billings, John Shaw, 79, 87
Bismarck, Otto von, 1 17, 201
Blacks, 234

access to medical care, 213

Flexner report on. 148-49

General Education Board and, 44, 45,
47

health status, 222, 224

in medicine, 88-89, 153, 154, 166,
259n59

Southern education movement and,
44--47
Blue Cross. 7, 199,205,208
Blue Shield, 205, 208
Bowditch. Henry Pickering, 72
Boylan, John, 169
Braverman, Harry, 25
Bryan, W. L., 86,252^6/
Bryan, William Jennings, 18
Buchez, P. J. B., 127
Butler, Nicholas Murray, 127, 172-74
Buttnck, Wallace, 46, 47, 54, 173. 184

California Institute of Technology, 27

Canada, 145

Cancer, 222, 229-30. 236, 269mS9

Capitalist society, medicine in, 12, 190,
241
see also Corporate capitalism; Cor-
porate class

Carnegie, Andrew, 9
castle in Scotland, 20, 53
General Education Board and, 57

gifts to birthplace, 32

"Gospel of Wealth," 30-32, 34, 48

growth of fortune, 15

higher education and, 31, 53, 143

innovations in industry, 52

labor relations and, 115, 249n98

limitations in philanthropy, 52

origins of Carnegie Foundation, 53, 143

on philanthropy, 31-32, 33

philanthropies, 31-32

Pritchett and, 53, 143

Rockefeller Institute and, 108

Social Darwinism and, 30-31, 33

Southern Education Board and, 241 n67

state universities and, 186

use of managers, 249n98
Carnegie Foundation for the Advancement
of Teaching, 5, 11, 179

attacks on, 124, 169

Committee on Costs of Medical Care
and, 195

Council on Medical Education and,
142^W

full-time plan and, 173

higher education and, 53-54, 143

medical profession interests and,
152-53, 155

origins, 53, 143

Pritchett's role in, 58-59

role in medical education reform, 189

state universities and, 53-54, 184-85,
186

see also Flexner report; Pritchett,
Henry J.
Carnegie Hero Fund, 32
Carnegie Institution of Washington, 108
Carr-Saunders, A. M., 68, 69
Carter, President Jimmy, 1
Case School of Applied Science, 27
Chambers, Frank R., 241n67
Cheney, Howell, 1 17
Civil War, 14-16,44, 114
Clark, Jonas, 29
Clark University, 27, 29
Christian, Henry A., 166
Crile, George W., 162
Curry, Jabez L. M., 44, 45, 46
Cushing, Harvey, 166-67
Coler, Birds., 169
Columbia University medical school,
172-74

Index I 275

Colwell, N. P., 140, 145, 146
"Commercialism" in medicine, 1 1,

147^8, 158, 194, 208
Commission on Industrial Relations,

United States, 170
Commission on Medical Education, 176
Committee for Economic Development,

210
Committee on Costs of Medical Care,

195-97, 199, 204, 209
Committee on Medical Research, 225-26
Comprehensive Health Planning agencies,

210, 211
Cooper Union, 27
Cornell, Ezra, 29
Cornell University, 27, 29
Corporate capitalism
growth, 16

scientific medicine and, 61
Corporate class

composition, 4, 206

foundations and. 4

medicine and, 4-5, 206-08, 210

medical education reform and, 136

medical research and technology and.

228-3 1
opulent homes of, 20
philanthropy and, 18
physicians and. 1 1 . 59
politics and, 19

social problems of industrialization and.
14
Corporate liberalism, 19, 54-55, 117-18,

175, 185, 187. 191. 200
Corporate philanthropy. 58
Council on Medical Education. 85
black medical schools and, 259n55
Carnegie Foundation and, 142^44,

152-53, 189
Flexner report and, 146, 153
full-time plan and. 163
reform strategy, 139-41, 150
state licensing boards and, 139^1
survey and classification of medical
schools, 139^0, 153
Crocker, Charles, 20

Dartmouth College. 26, 61
Debevoise, Thomas, 174
Debs, Eugene, 170
deforest, H. W., 172

Delafield, Francis, 102
Dellums, Ronald, 216-17"
Devine, Edward T., 21-22
Drake, Daniel, 85-86
DuBois, W. E. B.,241n69
Dubos, Rene, 129, 220, 235

East Germany, 221
Edsall, David, 167
Ehrenreich. Barbara, 92
Ehrlich. Paul, 76
Eliot, Charles W., 170

attacks on Rockefeller philanthropies
and, 171

on economic benefits of medicine, 1 18

A. Flexner and, 143-44

full-time plan and, 167-68, 172

Gates and, 262nl43

General Education Board and, 57

reform of Harvard medical school, 101 ,
151. 153
Elizabeth I. Queen of England, 43
Engels, Frederick, 131
England, 77, 85, 117, 139, 145, 221

National Health Insurance Act and
National Health Service Act, 201

primary care physicians, 215
England and Wales, 214, 220
English, Deirdre, 92
Ethics, codes of. 66. 68-70, 74, 88
Everett, Edward, 24

Falk. I. S., 197,211

Field, Marshall. 20

Fishbein. Morris, 96-97

Fisher, Walter, 113

Fisk, Jim, 20

Flexner, Abraham, 5, 84, 144-52. 154,

166, 193
AMAand, 151
early career, 144

full-time plan and, 156-57, 158, 164,

167, 172-75
Gates and, 156-57, 178

grants to state universities and, 177-78.

183
hired by General Education Board,

156-57, 165
on Johns Hopkins medical school, 145
Pritchett and, 144

276 I Index

Flexner, Simon, 108, 1 10, 11 1 , 1 12, 125,

144, 159
Flexner report, 157

AMA influence and, 143, 145-46,

151-52
blacks in medicine and, 148-49, 154
on class backgrounds of physicians,

148. 149
findings and recommendations, 146-51
impact, 152-56, 188
Johns Hopkins medical school and, 145
origins, 143-45
on proprietary medical schools, 1 1 , 84,

147-48, 150, 188
reactions of newspapers and medical

journals, 258-59«5i
women in medicine and, 149, 154
Flint, Austin, 102

Folk medicine, 78. See also Healers
Ford Foundation, 229
Fosdick, Raymond, 42, 183
Foundations
assets, 206

corporate class and, 58
corporate liberalism and, 187
origins, 9
physicians and, 9
professional-managerial stratum and, 9,

51, 186
rationalization of medicine and, 9, 175,

189, 195,207,210-11
role in medicine, 8-9, 175, 206-08,

210-11
support of medical education, 8,9, 193
support of medical research, 8, 193,

225-26,228-29,231
see also specific foundations by name
France, 11,76-71, 127, 139, 145
Franklin, Benjamin, 20-21
Freidson, Eliot, 68-70
Frissell, Hollis, 45, 46
Fuchs, Victor, 235, 236
Full-time plan

conflict with practitioners, 1 1 , 160-67,

189
General Education Board trustees and,

167-75
Harvard medical school and, 166-67,

174
impact on medical education, 176, 227
Johns Hopkins medical school and,
156-62, 164-65, 167, 175

origins, 157-160

rationalization of medicine and, 175

Gates, Frederick T., 10, 196

American Baptist Education Society

and, 34-35,36,40, 124
Baptist church and, 36, 38, 39, 124-25
compared with Pritchett, 189-90
compared with Rockefellers, 42
corporate liberalism and, 54-55, 132
early life, 38
Eliot and, 262nl43
A. Flexner and, 156-57, 178
fund raising and, 39-40
higher education and, 52, 54, 179-81
his income and wealth, 38, 40-4^1
on local "self-help," 47, 56-57
medicine and, 233, 240, 241

on economic benefits of, 112-13,

115-17
first public health school in U.S. and,

129
full-time plan and, 157-58, 172,

174-76, 227
on homeopathy, 105
impact on medical system, 194-95
interest in, 105-06, 111-12
on medicine's role in society, 11,
112-13, 122, 128-29, 133,
157-58, 189
on political benefits of, 122-25,

128-29
on private practitioners, 158, 194
role in medical education reform, 189
on value of medical research, 132-33
world view and scientific medicine,
119-21
on missionaries, 123-24
philanthropy and, 36, 41 , 42, 48-49, 52
professional-managerial stratum and,

52
on relations between capital and labor,

55, 130-32
religion and, 38-39, 123, 124-25
Rockefeller and, 34-37, 41, 43, 48, 49
Rockefeller, Jr., and, 41-42, 54-55
on Rockefeller's critics, 49-50, 171
Rockefeller's financial investments

and, 37,40, 41,42
role in Rockefeller philanthropies,
41-^2,51,54-56,58-59, 111
in General Education Board, 46, 48,

Index I 277

55-56, 187; defeats in, 175, 178,
191; trustees and, 55-57
in Rockefeller Foundation, 49, 55,

187
in Rockefeller Institute, 49, 105-109
the State and, 1 1
state universities and, 177-87
University of Chicago and, 34—35,

56-57. 180
on wealth, 43, 48, 49-50, 56
Welch and, 103
"wholesale philanthropy," 36
General Education Board

appropriations for medical education,

11, 57, 155, 189, 193
blacks and, 44, 45, 47
farm demonstration program and, 47
full-time plan and, 157-58, 163-76

passim
gifts from Rockefeller, 49, 50, 1 10,

165, 179
higher education and, 50, 57
impact on medical education reform,

155, 176, 189, 193
impact on medical system, 194
origins, 44-48

Southern education and economic de-
velopment and, 43, 44-48, 165,
247^67
state-run programs and, 181-82, 184
state universities and, 177-87
trustees' role in, 55-57
see also Gates, Frederick T.
Gerhardt, William, 75
Germany, 67, 71, 72, 76, 127, 139, 145,
160, 201
U.S. physicians trained in, 81, 82, 91,
102
Gibbs, Oliver Wolcott, 26
Gilman, Daniel Coit, 57, 145, 159
Gladstone, William E., 32
Goode, William, 68
Gould, Benjamin, 26
Gould, Jay, 20
Greenberg, Daniel, 230
Greene, Jerome D., 158, 170
Guerin, Jules, 127
Gynecologists, 213
Gynecology, 92, 96

Habermas, Jiirgen, 126
Haggerty, Robert, 223

Hahnemann, Samuel, 64, 105
Halsted, William S., 82, 99, 145, 156,

164-65
Hamilton, Alexander, 249n3
Hampton Institute, 44, 45, 247n69
Hanna, Mark, 19
Harkness, Edward S., 172
Harper, William Rainey, 35, 57
Harvard University, 24-25

medical courses in 1800, 61

medical school, 72, 87, 153
attitude toward A. Flexner, 146
full-time plan and, 166-67, 174
scientific medicine taught, 72-73
Healers, 61-62, 69, 78
Health insurance, private, 196-200, 202,
203

coverage, 213, 214

national health insurance and, 216, 217

premium income, 199, 205

role in medical system, 7, 205, 208,
239-40

share of medical expenditures, 1 , 7

see also Blue Cross; Blue Shield
Health Maintenance Organizations, 209,

210
Health Service Act, 216
Health status, 219-25

lifestyle and, 235-38
Health Systems Agencies, 210, 211
Helmholz, H. L. F. von, 91
Henry, Joseph, 25
Herbalists. See Healers
Higher education

Carnegie gifts to, 31

development in U.S., 24—30

professional-managerial stratum and,
192

see State universities; specific universi-
ties by name
Hill-Burton Act, 199-200, 202, 204, 226
Hobson, J. A., 123
Holmes, Oliver Wendell, 151
Holt, L. Emmett, 107, 108
Homeopathy, 74, 218

defined, 64

Gates' attitude toward, 105

origins, 64

regular profession and, 64

Rockefeller support of, 109-1 1

scientific medicine and, 88-89

see also Medical sects

278 I Index

Hoover, President Herbert, 103

Hopkins, C. W., 118

Hopkins, Johns. 29, 101

Hopkins, Mark, 20

Hospitals, 199

capital investment, 99, 203
expenditures on. 203, 205, 233
finances, 99-100
market system and, 205, 214
medical technology and, 7, 99, 203,

232
numbers, 99
physicians and, 99
rationalization and. 199, 209-10
reflecting class structure, 100
role in medical care system, 7, 99,

197-98
voluntary, 205

Howell, William H.. 145

Howland. Charles, 164-65, 167

Hughes, Everett, 69

Hughes, Hugh Price, 32

HuFl, Charles, 22, 23

Illich, Ivan, 2. 3, 235
Illinois Board of Health, 89, 136, 153
Industrial capitalism, 16-17, 58-59
Industrialism. See Technological deter-
minism
Industrialization

development of science, education, and

philanthropy and, 24-30
needs and problems, 13-14, 16-17
Interest groups in medicine, 4—5, 204—05,

226-28. 231-33
International Education Board. 184
International Health Commission, 116,

124
International Medical Congress, 93

Jane way. Theodore. 164—65

Japan. 77

Jefferson. Thomas, 62

Jenner, Edward. 76

Jessup, Morris K., 46

John Rockefeller McCormick Memorial
Institute, 108

Johns Hopkins University, 27. 29

first public health school in U.S.. 129
medical school. 72-73, 82, 84
Flexner report and, 145

full-time laboratory faculty, 81, 159
full-time plan and, 156-62, 164-65,

167, 175
preliminary education requirements,
87
Jones, William, 2A9n98
Josiah Macy, Jr., Foundation, 195, 229
Julius Rosenwald Fund, 195, 199

Kass, Leon, 236

Kellogg Foundation, 206, 210

Kelly, Howard, 82

Kennedy, Edward, 216-17

Kessner, David, 224

King, W. L. Mackenzie, 55

Klebs, Edwin, 76

Knapp, Seaman, 48, 181

Knowles, John, 236

Koch, Robert, 72, 76, 102, 128

Kresge Foundation, 206, 210

Labor unrest and organizing

medical care and, 1 14-15, 1 17-18

in 19th century, 17

philanthropy and, 22

see also Ludlow massacre
Lalonde, Marc, 235
Lambert, Alexander, 191
Landis, Kenesaw Mountain, 50, 168
Laura Spelman Rockefeller Memorial

Fund, 184
Lawrence, Abbott, 24-25, 27-28
Lawrence Scientific School, 25
Leubuscher, Rudolf, 127
Lewis, Charles, 214

Licensing, medical. See Medical licensing
Lifestyle and health status, 235-38
Lloyd, Henry Demarest, 19, 49
Lloyd George, David, 201
Loeffler, Friedrich, 76
London Charity Organization, 21
Lord, Nathan, 26-27
Lowell, A. Lawrence, 167
Ludlow massacre, 54-55, 130, 169-70
Ludwig, Carl, 72, 160
Lydston, Frank, 150

Mall, Franklin Paine, 145, 156-60, 162
Managers. See Professional-managerial

stratum
Martin, Franklin, 94

Index I 279

Massachusetts Institute of Technology,
27,53

Mather, Cotton, 20

May, Stacy, 1 16

Mayo, Charles, 162

Mayo Clinic, 99

McCormick, Edith, 108

McCormick, Harold F., 108

McCormick, John Rockefeller, 107

McGill University, 112, 165

McKeown, Thomas, 219-20

McKinley, President William, 19

McNemey, Walter, 236

Mechanic, David, 3

Medicaid, 202-05 passim, 208, 209, 21 1 ,
213-15,237

Medical care, 1

access and utilization, 1, 2, 196, 206,

212-15, 236-37
impact on health status, 2, 214,219-25,

235
market system, 4-5, 212-18, 240-^1
neglect of environmental factors, 2
social control and, 2, 235

Medical education. See Medical schools

Medical education reform, 188-91
early efforts, 65-66
laboratory science faculty and, 81-84,

87,95
medical faculty and practitioners,

82-88
19th century gains, 136
numbers of schools and students and,

85,87
physicians' class origins and, 85-88
proprietary medical schools and, 95
role in profession's refomn strategy, 135
role of corporate class, 1 36

Medical licensing, 63-65, 89-90, 139^1

Medical malpractice, 96

Medical profession. See Physicians

Medical research, 192
advances in, 73, 75-78
finances and expenditures, 101, 225,

226, 228, 229-30, 232-34
government support, 76-77, 225-32
in early 19th century, 71 , 73
in late 19th century, 72, 76-77
technical effectiveness, 112-13
see also Scientific medicine; Tech-
nology in medicine

Medical schools

AMAand, 8, 163-64, 188, 191
conflicts u'ith practitioners, 65-66, 67,

82
faculty influence and medical research,

226-28
finances, 82, 84, 101, 141^2, 176,

26Sn80
government support, 226-27
laboratory science faculty, 141
in 19th century, 61, 64-65
numbers of schools, 85, 135, 136, 154,

155
proprietary, 82, 84, 95, 147^8, 162,

188
role in medical system, 7
see also Medical education reform
Medical sects

AM A and, 66-67, 88-90
competition, 63-65, 66-67, 74, 80
Flexner report and, 154-55
scientific medicine and, 78, 88-91, 95
see also Homeopathy
Medical technology. See Technology in

medicine
Medicare, 202-05 passim, 208, 209, 211,

237
Medicine. See Physicians; Reductionism
in medicine; Scientific medicine;
Technology in medicine
Meharry medical school, 153, 165-66,

259n55
Midwives, 61, 78,96
Milbank Memorial Fund, 195, 229
Mill, John Stuart, 180
Miller, C. Arden, 238
Miller, Howard, 26
Missionaries and medicine, 122-24
Mott, Valentine, 71
Murphy. Starr J., 107

National Association of Manufacturers,

117, 118
National Cancer Institute, 219, 229-30
National Civic Federation, 19, 1 17
National Conference of Charities and

Correction, 21-22
National Education Association, 124, 169
National health insurance, 205, 237. 240
American Association for Labor Legis-
lation proposal, 1 17, 191, 201

280 I Index

National health insurance (cont.)
bills in U.S. Congress, 202, 216-17
in Europe, 1 17, 201

National Health Planning and Resources
Development Act, 210

National health service, 216-17, 240-41
in England, 201, 215

National Institutes of Health, 226, 227

Navarro, Vicente, 207

Neumann, Salomon, 127

New York Academy of Medicine, 71

Nixon, President Richard, 229, 237

Occupational health. See Workers
Office of Scientific Research and Dev-
elopment, 226
Office of Technology Assessment,

231-33
Ogden, Robert C, 44, 247^67
Osier, William, 89, 106, 161-62, 165

Page, Walter Hines, 57

Paine, Martyn, 86

Palmer, Potter, 20

Pasteur, Louis, 72, 77, 106, 107, 111,

112, 128
Pathological Society (of Philadelphia), 71
Peabody, George, 44
Peabody, George Foster, 57, 170, 2Aln67
Peabody Education Fund, 44, 45, 46
Peirce, Benjamin, 26
Peking Union Medical College, 124
Philanthropy

corporate class and, 14, 18, 58-59

corporate philanthropy, defined, 14/7

higher education and, 24—30

industrial capitalism and, 14, 22-30,
58-59

poverty and, 20-23

Rockefeller Institute as model, 132-33

science and, 24—30

"scientific," 21-22

Social Darwinism and, 21-22

"wholesale philanthropy," 36

see also Carnegie, Andrew; Gates,
Frederick T. ; Rockefeller, John D.
Philbrick, Inez, 87
Phipps, Henry, 108
Physicians, 5-6, 60

capitalist class and, 1 1 , 59, 70-71 ,
74^75

class origins, 85-88, 96-97, 148, 149

commodities and, 198-99, 204

competition, 60, 61, 74, 80, 135

distribution, 214-15

elite, defined, 65/i

employment in institutions, 6

heroic medical practices, 62-63, 73, 76

hospitals and, 99

income, 5, 6, 64, 67, 81, 82, 91, 157,
230

laboratory testing and, 232-33

Medicaid and, 213

medical practices in 19th century,
61-66,79,98-99,218

medical technology and, 197-98, 232

other health workers and, 6

other medical interest groups and, 6

"overcrowding," 135, 147, 150

in primary care, 2, 215

professionalization, 63-71, 94—97,
192, 239

specialization, 73, 91-94

status, 6, 60-63, 67, 135

technical effectiveness, 67, 70, 71,
73-79, 91

-to-px)pulation ratio, 67, 94, 147, 214,
215

training in Europe, 61, 72, 73, 81-82,
91
Pillsbury, George, 39
Popular Health Movement, 63
Populism, 17-18,63,69

and medical profession, 63, 69, 70
Poverty

access to medical care and, 96, 212-15

health behavior and, 236-37

health status and, 220-22

philanthropy and, 20-23

Rockefeller on, 33
Powles, John, 220
Pratt Institute, 27
Primary care, 215, 223, 225
Pritchett, Henry S.

AMAand, 143-45, 151-53, 190

attitude toward Gates, 54

Bevanand, 143, 144, 151-53, 190,
259/155

black medical schools and, 153

Carnegie and, 53, 54, 143

compared with Gates, 189-90

Flexner report and, 143-45

full-time plan and, 173

General Education Board and, 54

Index I 281

hiring A. Flexner, 144
medical profession interests and,

152-53
role in Carnegie Foundation, 53, 58-59
role in medical education reform, 189
Professional-managerial stratum
development, 9, 14, 51, 58-59, 192
philanthropy and, 51, 186
rationalization of medical care and,
204, 208
Progressive movement and party, 49, 1 17,
126, 131, 132, 168, 169,174, 191,
200, 201
Public health programs, 47^8, 103,

115-17, 124
Public health school, first in U.S., 103,

129
Public Health Service, United States, 225
Pusey, Robert, 79

Railroads, 15-16
Rauscher, Frank J., Jr., 229-30
Rationalization
in industry, 51

in medical care, 6-9, 193-96, 199-203,
204-12, 237, 239^1
defined, 6, 8
full-time plan and, 175
private practitioners and, 191
Reader, W. J., 85
Reductionism in medicine. 10, 75,

119-22, 127-30, 133, 228-31
see also Scientific medicine; Tech-
nology in medicine
Reed, Charles A. L., 84, 90, 137
Religion, 31-40 passim, 64, 105, 121,

122-25, 127
Rensselaer Polytechnic Institute, 27, 29
Roberts, John B., 125
Robert Wood Johnson Foundation, 206,

210
Rockefeller, David, 187
Rockefeller, John D.

attacks on, 49, 168-70, 182
attitude toward science, 1 10-1 1
Baptist church and, 32-33, 34, 123
Commission on Industrial Relations

and, 170
contrasted with his son and Gates, 42
Gates and, 34-37,41,43,54
gifts to

General Education Board, 46, 49,

50, 165, 176-77, 179
Rockefeller Foundation, 49
Rockefeller Institute, 104, 105, 108
University of Chicago, 56
grow th of fortune , 15-16
homeopathy and, 109-1 1
innovations in industry, 52
philanthropy and, 9, 18, 32-33, 35-36,

52
Pocantico Hills estate, 20
politics and, 19
poor health, 35

Rockefeller Institute and. 49, 105-09
role in Rockefeller philanthropies,

41-42,50-51, 111
and his son, 41^2, 56
Standard Oil Co. and, 35
University of Chicago and, 34—35,

56-57, 180
views on wealth and poverty, 33, 43
Rockefeller. John D., Jr., 52, 56
Commission on Industrial Relations

and, 170
contrasted with his father and Gates, 42
corporate liberalism and, 54-55, 187
and his father, 41-^2, 56
first public health school in U.S. and,

129
Gates and, 41^2. 54-55
on Gates' role in General Education

Board, 48, 111
origins of General Education Board

and, 46, 49
professional-managerial stratum and,

52
role in Rockefeller philanthropies,

41-^2,51.54,56, 111
in Rockefeller Institute. 107-09
in Rockefeller Sanitary Commission,

116
on philanthropy, 52
Southern education movement and, 44,

46
on state universities. 184, 186
Rockefeller Foundation, 195, 206
attacks on, 169-70
charter problems, 169
full-time plan and, 173, 176, 227
gifts from Rockefeller, 49
grants to medical schools, 189
political uses of medicine, 122, 124,

129

282 I Index

Rockefeller Foundation (cont.)

role in medical education reform, 189

role in medicine, 210

state universities and, 182, 183, 184

support for medical research, 229

see also International Health Com-
mission; Peking Union Medical
College
Rockefeller Institute for Medical
Research, 49, 127,228

biological reductionism and, 129

Carnegie Institution of Washington and,
108

gifts from Rockefeller, 104, 105, 108

homeopathy and, 1 10

as model, 132-33

origins, 105-09

political value of, 128
Rockefeller philanthropies, 196

attacks on, 168-71, 182

corporate liberalism and, 1 1

Gates role in, 58-59

role in medicine, 104, 225. 239
Rockefeller public health programs, 48,

103, 115-17, 124
Rockefeller Sanitary Commission for the
Eradication of Hookworm Dis-
ease, 115-16, 130
Rogers, David, 234

Roosevelt, President Theodore, 49, 168
Root, Elihu, 184-85
Rorem, C. Rufus, 199
Rose, Wickliffe, 184
Rothstein, William, 65, 90
Rush, Benjamin, 62, 161
Rush medical college, 107, 109
Russell Sage Foundation, 2Aln67

Sanitary Commission, United States, 1 14,

115
Schooling, compulsory, 23-24
Science, development in U.S., 24-30,

192
Scientific management, 75, 126
Scientific medicine, 10

capitalism and, 10-11,61,98, 193,241
contradictions for medical profession,

98
defined, 219

economic benefits for physicians, 193
as ideology of professionalization,

10-11,60,71,73,74-80.95, 193

industrial world view and, 74
medical education reform and, 95-97
medical practice and, 73, 75-76, 79
medical sects and, 78, 8^-91, 95-97
physicians' technical effectiveness and,

95-96, 193
social medicine and, 127-28
specialization and, 91, 95
as substitute for religion, 124-25, 127
see also Reductionism in medicine;
Technology in medicine

Scotland, 61

Sears, Bamas, 44

Sects. See Medical sects

Sheffield, Joseph Earl, 26

Sheffield Scientific School, 26

Sherman, John, 19

Shryock, Richard. 77

Silliman. Benjamin, Jr., 26

Simmons, George H., 137, 138, 140-41,
145

Slater, John F., 44

Slater Fund, 44, 45, 46-47

Slavery and medicine, 1 13-14

Sloan, W., 172

Social Darwinism, 21-22, 52
Carnegie and, 30-31, 33

Social medicine, 127-28

Social Security Act, 202

Socialism, 14, 43, 50, 131, 201, 216

Socialist party, 49, 132, 170, 174, 201

Society of Clinical Surgery, 162

Somers, Anne, 234

Southern economic development. 43,
44-48. 165

Southern Education Board, 44 45, 46,
2Aln67

Specialization

competition with general practitioners,

73, 92-94, 95
fee-splitting and, 93-94
physicians incomes and, 91-92
primary care and, 94
scientific medicine and, 91 , 95

Spencer, Herbert, 21, 30

Standard Oil Co., 16, 35, 49, 50, 54, 168

Stanford, Leland, 20, 29

Stanford University, 27, 29

State, the

corporate class and, 200-201

defined, 9n

medical care expenditures, 1

Index I 283

medical research and, 16-17, 225-232,

234
medical technology and, 218
national health insurance and, 217-18
rationalization of medical care and,

200-03, 207-12, 218
role in medicine, 8, 9, 12, 195, 205,
239-40

State universities, 1 1, 47, 53-54, 177-87

Stevens, Rosemary, 99, 162, 193

Stevens Institute, 27

Stiles, Charles Wardell, 115-16, 129-30

Stokes, Anson Phelps, 171, 174

Surgery, 92, 214

Sweden, 221

Tarbell, Ida, 49, 168

Taylor, Frederick W., 126

Technological determinism, 2-A, 126
Marxist critique of, 3

Technology in medicine, 3, 239-40
corporate class and, 4, 228-31
costs, 233-34
decline, in support, 234—38
health work force and, 6
impact on health status, 223-25
medical technology industry, 204-05,

231-33,239
physicians incomes and, 6, 232
role in medical system, 198, 215

Topping, John, 1 15

Tuberculosis, 220, 223, 225

Tucker, William Jewett, 32

Tulane University, 27

Tuskegee Institute, 44, 45

Universities. See Higher education; State
universities; specific universities
by name

University of Chicago, 34-35, 56-57, 179
full-time plan and, 165, 175
Rush medical college and. 107, 109

University of Cincinnati, 183

University of Colorado, 1 83

University of Georgia, 183

University of Iowa, 177, 183, 184

University of Michigan, 153

University of Oregon, 183

University of Pennsylvania, 27, 61, 72-73

Van Rensselaer, Stephen, 27
Vanderbilt family, 20

Vanderbilt University, 27, 165, 175
Vaughan, Victor C, 150, 161
Villerme, Louis Rene, 127
Vincent, George, 124, 171, .184
Virchow, Rudolf, 72, 127

Wall, Joseph F., 52

Walsh, Frank, 170

Wanamaker, John, 44

Warner, Amos, 22

Washington, Booker T., 45, 241n69

Washington University at St. Louis, 165,
175

Watson, Tom, 18

Welch, William H., 86, 111, 112, 145,
156, 157
AMAand, 191
career, 102-04

desire for career in research, 81-82, 159
on economic benefits of medicine, 1 18
first pathology laboratory in U.S., 72
first public health school in U.S. and,

103, 129
full-time plan and, 164—65
Gates and, 103
on private practitioners, 191
Rockefeller medical philanthropies
and, 103-04, 108

Wharton, Joseph, 27

Wilbur, Ray Lyman, 264n4

Wilensky, Harold, 68-69

Wiley, Harvey, 25 1 n40

Williams, William Appleman, 58

Wilson, Charles, 240

Wilson, President Woodrow, 170

Winkelstein, Warren, 222

Women in medicine, 88, 96, 149, 154

Workers

conditions, 16-17,23, 114-16,220
development of industrial work force,

16
Gates on workers, 130-32
health status, 113, 116-19, 220,

222-23, 230,231,238
occupational cancer, 229
see also Labor unrest and organizing

Yale Scientific School, 26

Yale University, 26, 72-73

Yale University medical school, 165, 175

Zinsser, Hans, 227

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